Wagashi Special Class Enrolment Wagashi Special Class Enrolment Page 1 Page 2 Name Child's Details Child's Surname * Child's Given Name(s) * Date of Birth * Gender * Male Female Home address * Suburb * State * Postcode * Medical Information Does your child have any food allergies? * Yes No Does your child have any dietary requirements (including cultural/religious requirements)? * Yes No Has your child been diagnosed at risk of anaphylaxis? * Yes No Anything else you would like to tell us about your child's health: Parent/Guardian Details Parent's Surname * Parent's Given Name(s) * Relationship to child * Mobile number * Home phone Email address * Medical History and Information Do you have any food allergies? * Yes No Do you have any dietary requirements (including cultural/religious requirements)? * Yes No Have you been diagnosed at risk of anaphylaxis? * Yes No Anything else you would like to tell us about your health: Do you give permission for photographs and video of yourself and/or child to be featured on the Mochi Music website and associated social media sites? * Yes, both myself and my child Only myself Only my child No photographs or video please
