First Name

Last Name

Date of birth

Address

Street Address

City

State

Country

Postal Code

Email *

Phone *

Have you/ your child had any previous dance experience? *

Yes

No

If ‘Yes’ please give details:

Emergency Contact Information- Full Name *

Emergency Contact Information- Contact Number *

Emergency Contact Information- Relationship *

Are you/ your child currently being treated by a Doctor/Specialist? *

Yes

No

If ‘Yes‘ please give details

Have you/ your child had any Sprains / Breaks / Injuries within the last 2 years? *

Yes

No

If ‘Yes’ please give details

Have you/ your child seen a Doctor / Physiotherapist in the last 3 years with a joint / Muscle / Bone problem? *

Yes

No

If ‘Yes’ please give details:

If selected please give details:

Have you/ your child got any allergies? *

Yes

No

If ‘Yes’ please give details:

Are you/ your child currently on or have been on any long-term / permenant medication? *

Yes

No

If ‘Yes’ please give details:

Do you/ your child have any other injuries or medical conditions which might be relevant? *

Yes

No

If ‘Yes’ please give details:

Do you/ your child have any injuries at present? *

Yes

No

If ‘Yes’ please give details:

Do you/ your child have a disability? *

Yes

No

If ‘Yes’ please give details:

Are you/ your child registered as disabled? *

Yes

No

If ‘Yes’ please give details:

Do you/ your child suffer from any visual impairment? *

Yes

No

If ‘Yes’ please give details:

Waiver of liability

ON BEHALF OF THE STUDENT

Acknowledgement of Risks

· I, hereby acknowledge that participation in physical exercise and training activities at Stratford Dance Academy involves risks of injury. These risks include, but are not limited to, muscle strains, ligament sprains, falls, contact with other participants, and the effects of the weather, including high heat and humidity.

Health Declaration

• I confirm that I am/ student is in good health and have no medical condition that would prevent their participation in physical exercise.

• I agree to inform Stratford Dance Academy of any changes in my/my child’s health status that may affect safe participation in physical activities.

Waiver of Liability

• I agree to assume full responsibility for any risks, injuries, or damages, known or unknown, which might occur as a result of participation in physical activities at Stratford Dance.

• I knowingly and voluntarily waive any claim I may have against Rhythm Revolution Dance Academy, its employees, and instructors for injury or damages that I may sustain as a result of participating in the program.

Use of Image

• I grant permission to Stratford Dance Academy to use photograph and/or video image of the student in publications, websites, and other media for promotional purposes.

Agreement to Follow Instructions

• I agree to follow the safety instructions provided by Stratford Dance Academy staff and to use equipment properly and as instructed.

Acknowledgement and Signature

· I have read and fully understand the contents of this waiver and voluntarily agree to its terms.

Signature

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