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Soul in Motion dance classes
Under 18s form
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* Indicates required question
Parent/Guardian Name
*
Your answer
Email
*
Your answer
Phone Number
*
Your answer
Emergency Contact Number
*
Your answer
Child's name
*
Your answer
Child's Date of Birth
*
MM
/
DD
/
YYYY
Is your child on any medication?
*
Yes
No
If yes, please list the medications
*
Your answer
Has your child got any health conditions?
*
Yes
No
If yes, please list health conditions
*
Your answer
I provide consent to photograph my child during class to be used to promote their success on social media and website
*
Yes
No
I provide consent to video my child during class to be used to promote their success on social media and website
*
Yes
No
I declare that the above information is correct and I understand that it is my responsibility to advise the dance teacher of any change in my child's medical information provided.
*
Agree
Required
How did you hear about Soul in Motion dance classes?
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Leaflet
Other:
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