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Injury Intake Form
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* Indicates required question
Email
*
Your email
Dancer's Name
*
Your answer
Parent's Name
*
Your answer
Parent's cell number
*
Your answer
Date of injury
MM
/
DD
/
YYYY
Please describe the injury. (Where is it, how did it occur, and what activities or movements cause pain.
*
Your answer
Do you plan to see a doctor for the injury?
*
Yes
No
Maybe
Please select your dancer's participation level for class.
*
My dancer will not participating, they will be observing. (Please contact us when this changes).
My dancer will be participating with modifications. (*Please provide more information regarding this below).
My student will be taking class with no limitations.
If your dancers will be participating "with modifications", please list them here so we can communicate them to all supporting instructors.
Your answer
Other information you'd like to share with GDS staff. For example, "plan of action", "appt details", etc.
Your answer
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