Health Questionnaire

Health Questionnaire
Childs Full Name
Date of birth
Age
Gender
Parent/Guardian Name
Address
Postcode
E-Mail
Home Phone Number
Work/Mobile Number
Doctors name
Doctors Phone number
Medical History - Does your child have any of the following Diabetes/ Asthma/ Respirory/ Heart/ Epilepsy/ Recent Surgery/ Allergies or Joint Problems
Please give a brief history of Dance/Theatre experience your child has & List Exams
I agree to give 2 weeks notice in writing/verbal	I Agree
I agree to let my child be photographed or filmed for educational/advertising or editorial purposes of DANZ STUDIO only	I Agree
I acknowledge the above to be true and accurate regarding my childs health	I Agree

For further infomation contact Danz Studio on 07813 154158