Thrive Community Dance Class Registration Form

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Thrive Community Dance Class Registration Form - Logan 2022

Please fill out this form for participation in Dance for Parkinson's classes. This information helps us to keep in touch and to ensure best practice safety measures during classes. The information you provide on this form will be treated with the utmost confidentiality and will only be used to assist you in an emergency. For more information: www.dancepdau.org

Email *

Full Name *

Phone number *

Emergency contact full name *

Emergency contact phone number *

Relationship of emergency contact to participant *

Address: Please consider providing your address. An address can help us coordinate emergency services if needed. This address will not be shared and will only be used for emergencies.

Location interested in

Jimboomba - Mondays

Kingston - Gould Adams Community Centre -Tuesdays

Disclaimer: I hereby acknowledge that the information provided above, to the best of my knowledge, is correct. I will inform the Instructor immediately if there are any changes to the above information. I acknowledge that during physical activity classes, an accident may occur involving injury or damage. I indemnify the Instructor and DPA from all legal actions, injury claims, loss, damage, penalties and costs arising from my participation in this physical activity program. *

Required

I agree to have my details held in the Dance for Parkinson's database for contact purposes and for disseminating information regarding the program *

Do not accept

Required

Any additional comments or information- please use the space below? We look forward to dancing together!

Send me a copy of my responses.

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