New Starter Questionnaire – Kerry's Dance Collective

Health Questionnaire Form

Your Information
Childs Information
Emergency Contact
Medical Information
Consent

Your Information

Information about you (the parent/carer)

Parents Full Name

Phone/Mobile

Your Address

Address Line 1

City

Postcode

Childs Information

Information about the child joining us

Childs Full Name

What Does Your Child Like to Be Called? (if not their full name)

Childs Date of Birth

Emergency Contact Name

Emergency Contact Phone

2nd Emergency Contact Name

2nd Emergency Contact Phone

Medical Information

Any medical information we should know about your child?

Known Medical Conditions eg. Asthma

Medication Taken eg. Inhaler

Registered GP

Registered GP Contact Number

GP Address

Address Line 1

City

Postcode

Consent

Please provide consent

I confirm in the event of an emergency I give permission for someone to seek medical assistance from the students practitioner, first aider or emergency service.

If my child is walking home or being being collected outside I understand I am responsible for them once they have left the class.

I give permission for the above student to appear in photographs and videos taken to be used for publicity purposes including social media.

Yes

Anything else you would like to tell us that might help us provide a better dance experience for your child?

I consent to this website storing my submitted information so they can provide a safe experience for my child in their classes, and to being contacted using any of the information provided with information about the classes or anything else that may be deemed useful to hear about.

KDC New Starter Questionnaire

Your Information

Childs Information

Medical Information

Consent

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