If you would like to register, please complete the booking form below. We will send you confirmation of a place and a request for payment.

Name of Child *

Date Of Birth *

After School Academies

Belper Youth Theatre, Long Row School, Derbyshire, Wed 5-6pm Where applicable

LAMDA Tuition

Long Row School, Belper, Derbyshire (Wed 4.30pm-5pm) Walter Evans School, Darley Abbey, Derbyshire (Tues 4.30pm-5pm) St John's School, Belper (Mon 4.30pm-5pm) Where applicable

School Holiday Workshops

Belper, Derbyshire (26-27 October 2009 Bakewell, Derbyshire (28-29 October 2009) Uttoxeter, Staffordshire (2-4 November 2009) Where applicable

Parent/Guardian name *

Telephone * Mobile

Emergency Contact Name/Telephone *

E-mail address *

Address

*

Comments / Questions

Does your child need any medication on a permanent basis or suffer from any severe allergies?

Yes No

* required information