Health Questionnaire

Health Questionnaire

• Childs Full Name:*
• Date of birth:

  • Day12345678910111213141516171819202122232425262728293031
  • MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
  • Year1939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029
• 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