Medical and registration form

ALL INFORMATION WILL BE KEPT CONFIDENTIAL

Full Name

Address

How Did You Hear About The Class?

Contact Telephone Number

In Case of Emergency, Please Provide a Name and Contact Number

Are there any medical issues which may affect your participation in a dance class that we need to be aware of? Or should something happen to you, is there anything that might be useful information when seeking emergency medical care?

I confirm that I have completed the above questionnaire to the best of my ability and that I have provided accurate information regarding my current health status. I take it upon myself to discuss any changes in my health with the teacher and my Doctor. I understand that any dance/exercise class has certain risks. I understand that the degrees of risk depend on my health and physical fitness. I am voluntarily participating in classes with Sonia Brown, and will immediately discontinue any activity if I feel any symptoms of distress or discomfort, and will notify the tutor.

I confirm that I have read, understand and agree to the privacy agreement.View privacy agreement