Health Questionnaire

APPLICATION FORM

TO BE COMPLETED BY THE PARENT OR GUARDIAN OF THE PARTICIPATING CHILD

Name:
Email:
Date of Birth:
Age:
Gender:
Address:
City:
Postcode:
School:
Emergency Contact Numbers
Home:
Work/Mob

Email:
Doctor Name:
Doctor Contact Number:
Give a brief history of any theatrical or dance experience your child has (List exams)

Does your child have or has a history of any of the following Diabetes/Asthma, Respiratory/ Heart/Epilepsy/Recent surgery/ Allergies or joint problems. are they currently taking any medication

Due to the limited spaces we have in classes I would ask you to agree to the following. I AGREE TO GIVE 5 WEEKS NOTICE IN WRITING OR I WILL BE CHARGED 5 WEEKS FEES. WE WILL PURSUE THIS MATTER. We occasionally video or photograph students as they dance. This could be for educational/ advertising or editorial purposes.. If you would not like your child to be videoed or filmed please let us know immediately. I agree to let my child be photographed or filmed for the above purposes only. I ACKNOWLEDGE THE ABOVE TO BE TRUE AND ACCURATE REGARDING MY CHILDS HEALTH. I authorise any responsible adult acting as a teacher to sign on my behalf any written form or consent required by the hospital, for any anaesthetic to be administered, or for any other urgent medical treatment to be given, provided the delay required to obtain my own signature might be considered in the opinion of the doctor concerned, a danger to my child’s health and safety.