Health Questionnaire

Health Questionnaire

• Childs Full Name:*
• Date of birth:

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• Age:*
• Gender:*Please choose one of the following…FemaleMale
• 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
• Send