REGISTRATION & MEDICAL FORM

Enrolling Students

Student 1

Student First Name

Students Last Name

Students Date of Birth

Students Sex (For show chaperones)

Student 2

Students First Name

Students Last Name

Students Date of Birth

Students Sex (For show chaperones)

Parent / Guardian Contact Details

Primary Parent / Guardian

Parent/Guardian First name

Parent/Guardian Last name

Relation to Enrolling Student(s)

Main Contact Number

Parent/Guardian Email

Primary Parent / Guardian Home Address

House No.

Street

City

County

Post Code

Second Parent / Guardian

Parent/Guardian First Name

Parent/Guardian Last Name

Relation to Enrolling Student(s)

Main Contact Number

Second Parent / Guardian Home Address

House No.

Street

City

County

Post Code

Medical / Food Allergies

Food Allergies: For each allergy, include details such as 1) Food Allergen, Type/severity of reaction, 2) Whether an epinephrine auto-injector is prescribed etc., 3) Emergency action plan or 4) Instructions

Please list only medically diagnosed food allergies that would require emergency medical attention if the food is ingested, stating which student if more then 1 enrolled.

Medical Conditions: For each medical condition, please include details such as 1) Type/severity of reaction, 2) Whether an inhaler is prescribed etc., 3) Emergency action plan or 4) Instructions

Please list any medical conditions the enrolling student has, stating which student if more then 1 enrolled.

Learning Difficulties: Please let us know if your child has a diagnosed learning difficulty, so we can provide appropriate assistance, particularly when taking exams / medals if they so choose.

Please let us know if the child is neurodivergent, stating which student if more then 1 enrolled.

Signature

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Where did you hear about Just Dance Performing Arts

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