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DANZ STUDIO
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Contact Dan
More
Menu
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Health Questionnaire
Health Questionnaire
Childs Full Name:
*
Date of birth:
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Age:
*
Gender:
*
Please choose one of the following…
Female
Male
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
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