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Dance Progressions Medical Form
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* Indicates required question
Student Name
*
First and Last name.
Your answer
DOB:
*
MM
/
DD
/
YYYY
Parent 1 Name
*
First and Last name
Your answer
Best Phone Number
*
Your answer
Parent 2 Name
First and Last
Your answer
Best Phone Number
Your answer
Emergency Contact (*other then Parent 1 or 2)
*
First and Last name, and phone number
Your answer
Preferred Hospital
*
Your answer
Physicians Name and Phone Number
*
Your answer
Insurance Company and Policy Number
*
Your answer
In case of extreme emergency, I give my permission for my dancer to be transported to the hospital via ambulance if deemed necessary at my/insurance providers's expense.
*
Signed
Does your dancer have any allergies? Allergies to medications?
*
If none, type N/A
Your answer
Does your dancer have any previous injuries?
*
If none, type N/A
Your answer
Other medical conditions/necessary information
*
If none, type N/A
Your answer
While Dance Progressions strives to provide a safe and clean environment, I (parent) acknowledge the inherent risks of group activity during a global pandemic and hold Dance Progressions, LLC harmless.
*
Signed
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