Kathleen Gorham Scholarship - Royal Academy of Dance

Kathleen GorhamMemorial ScholarshipSunday 11 November 2012The Primrose Potter Australian Ballet Centre,Level 5, 2 Kavanagh Street, SouthbankClosing Date: Friday 19 October 2011Summary FormFEE: $25 per student (incl. GST) entry fee is non refundableName of Ballet School____________________________________________________________________________________________Teacher’s NameRegistration No.____________________________________________________________________________________________Correspondence Address____________________________________________________________________________________________EmailPhone____________________________________________________________________________________________STUDENT DETAILS (please print clearly)Name M / F Level AmountTOTAL $Teacher Signature: _______________________________________Date: ___ / ___ / ____I HAVE READ AND UNDERSTAND THE CONDITIONS OF ENTRYMETHOD OF PAYMENT (please tick) I have enclosed ONE cheque to the amount of $ __________________ (made payable to RAD Victorian Panel) Please charge my credit card with the amount of $ _________________ ( VISA / MASTERCARD )Card No: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __Expiry date: __ __ / __ __Name on Card: __________________________________________________________________________________Signature: __________________________________________Date: ___ / ___ / ____PLEASE RETURN COMPLETED SUMMARY FORM WITH INDIVIDUAL STUDENT FORMS AND PAYMENT TO:RAD VIC PANEL ENTRIES SECRETARY55 / 88 Southbank Blvd Southbank VIC 3006jillannereynold@optusnet.com.au