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Soul in Motion dance classes
Over 18s form
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Name
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Your answer
Email
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Your answer
Phone Number
*
Your answer
Emergency Contact Number
*
Your answer
Date of Birth
*
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YYYY
Are you on any medication?
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Yes
No
If yes, please list the medications
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Your answer
Have you got any health conditions?
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Yes
No
If yes, please list health conditions
*
Your answer
I provide consent to be photographed during class to be used to promote my success on social media and website
*
Yes
No
I provide consent to be filmed during class to be used to promote my 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 medical information provided.
*
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How did you hear about Soul in Motion dance classes?
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