Adult registration/medical form

First name

Last name

Birthday

Email

Phone

Address

Emergency Contact and name

Medical History. Click if it's a yes and please specify any medical or personal information here that you think that I should know about.

Has your doctor ever said you have heart problems?

Do you frequently have pains in your heart and chest?

Do you often feel faint or have spells of severe dizziness?

Has a doctor ever said your blood pressure was too high?

Has your doctor ever told you that you have a bone or joint problem such as arthritis that has been aggravated by exercise, or might be made worse with exercise?

Is there a good physical reason, not mentioned here, why you should not follow an activity program even if you wanted to?

Are you over age 60 and not accustomed to vigorous exercise?

Do you suffer from any problems of the lower back, i.e., chronic pain, or numbness?

Are you currently taking any medications? If YES, please specify above.

Do you currently have a disability or a communicable disease? If YES, Please specify above.

Are you currently pregnant? If YES, how many weeks.

The information that I have provided is, to the best of my knowledge, both true and accurate. I agree to advise the dance teacher of any changes in my health condition which may affect my ability to exercise.

I confirm that I am voluntarily engaging in the dance classes and understand that the classes will involve cardiovascular exercise, strength and balance which in some circumstances creates a risk of personal injury. I am aware of and accept theses risks and am responsible for my own actions and involvement.

Please sign below to confirm that you have agreed to participate in the dance classes and that you understand the risks involved. All information on this form is confidential.

How did you hear about Dance Off?

I hereby give permission for Dance Off to use my image both photography/films for marketing purposes.

Yes

No

Signature

Date

Adult dancers registration and medical form