Registration Form

Please fill out the form below

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Medical Declaration

All information on this form will be treated with the strictest confidence and be collected and stored with Emma Clare School of Dance’s GDPR Policy.

Student’s Name(Required)

First Last

Student’s Date of Birth(Required)

Day

Month

Year

Parent/Guardian’s Name(Required)

First Last

Parent/Guardian’s Telephone Number(Required)

Parent/Guardian’s Email Address(Required)

Who will usually collect your child?(Required)

Alternative emergency contact name(Required)

First Last

Alternative emergency contact Telephone Number(Required)

Medical Information

Does your child have any of the following?(Required)

NONE - my child has no medical conditions

Asthma

Any Allergies

Any Skin Conditions

Hearing Impairment

Visual Impairment

Any Physical Disability

Any Learning Disability or SEN

Any Medical Conditions

Any Regular Medications

Notes (including treatment) relating to ASTHMA(Required)

Notes (including treatment) relating to ALLERGIES(Required)

Notes (including treatment) relating to SKIN CONDITIONS(Required)

Notes (including treatment) relating to HEARING IMPAIRMENT(Required)

Notes (including treatment) relating to VISUAL IMPAIRMENT(Required)

Notes (including treatment) relating to PHYSICAL DISABILITY(Required)

Notes (including treatment) relating to LEARNING DISABILITY or SEN(Required)

Notes (including treatment) relating to MEDICAL CONDITIONS(Required)

Notes (including treatment) relating to REGULAR MEDICATIONS(Required)

Has your child been to see or had a referral to a hospital consultant in the last 6 months(Required)

Yes

Notes regarding hospital referral(Required)

Hands on Adjustment

To aid the teaching of dance and to assist technique, it is sometimes necessary for the teacher to use a hands-on approach (e.g to gently adjust the turnout in the legs)

Disclaimer

I acknowledge and fully understand that my child will be engaging in a physical activity that may involve some risk or injury. I assume full responsibility for any injury or accident that may occur and understand that neither the teacher nor the facility is held liable for any injury or loss or damage of property during class. I understand it is my responsibility to disclose any past, present or future illness or injury that could affect my child’s participation in the dance class.

I authorise the teacher, Emma Edge, to contact the alternative contact I have provided if the event of an incident or accident I cannot be reached.

Signature(Required)

I confirm that as a parent/carer/guardian with parental responsibility regarding the student, I have no knowledge or concerns that would prohibit their ability to take part in classes safely.

Your Name
Your Name
Your Name

Name(Required)

First Last

Date(Required)

Day

Month

Year

Information for Parents

The Church has its own private car park, this provides free parking for all hall users.
Please send your child with a drink and long hair tied back.
We run a no food policy at the hall and ask that pupils eat before attending their class.
Pupils are asked to arrive 5 minutes before their class start time, this way we can start the session on time.
Parents are asked to drop their child off and return at the end of the class to pick them up.
Please ask your child to try the toilet before their class.
Fees are due within 7 days of receiving an invoice.

More information available through the website on the ‘Frequently asked Questions’ page.

Name