Registration Form

Health Questionnaire

www.sarahbellydance.co.uk
sjgarrish@googlemail.com
07815 549581

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

Emergency Contact and Number *

How did you find out about these classes? *

Please list any medical conditions or injuries which you have. Medical conditions to inlude are: Heart conditions, high blood pressure, Epilepsy, Diabetes, Arthritis, Asthma, muscular pain, dizziness or fainting *

Are you taking any prescribed medication at present? Please advise what and why. *

If you answered yes to the above question, are there any side effects? Please advise on what these may be. *

Are you, or could you be, pregnant? *

Yes No

Statement: I recognise that the teacher is NOT able to provide me with any medical advice with regard to my medical fitness, and that the information given is only to be used as a guideline to the limitations of my ability to dance. I have answered the questions to the best of my knowledge, and I understand the above advice. I also undertake to advise the teacher if any medical condition/s develop/s which might affect my ability to dance.

By sending this form you agree to the terms and conditions mentioned in the statement above. Please print these terms and conditions and retain for your information.

All the personal information you provide on this form is used in the strictest of confidence and will not be passed on to third parties. I will only use this information should I need to get in touch in case of emergency, class cancellation or to notify you of upcoming events.

Would you like to be kept informed of any events taking place locally? *

Yes No

Submit