POLE ATTACK KIDS PARQ
Personal Information
Today's Date
*
Childs Full Name
*
First Name
Last Name
Pronoun if relevant
Childs Birth Date
*
Please select a day
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Day
Please select a month
January
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November
December
Month
Please select a year
2026
2025
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1921
1920
Year
Child's Address
*
Street Address
Street Address Line 2
City
County
Post Code
Parents E-mail
*
Mobile Phone Number
*
-
Area Code
Phone Number
MEDICAL INFORMATION
Has your child had surgery in the last 6 months?
*
Yes
No
Has your child ever had, or do they currently suffer from any of the following?
*
Epilepsy
Bone or Muscle Problems
Asthma/Respiratory Problems
Thyroid Problems
Heart Problems
Ligament or Tendon Problems
Dizziness/High or Low Blood Pressure
Blood Disorders
Circulatory Problems
Allergies
None of the above
If stated yes to any of the above, please explain
Is there anything else you should tell us regarding your child's current, or previous health?
*
Is your currently taking any medicine that may affect their heath in class?
*
Yes
No
If stated yes, please explain.
Does your child have any allergies? – (If your child has any severe allergies that require immediate medication, you must ensure they always have their medication in class.)
*
Yes
No
If stated yes, please explain
Does your child have Asthma? - (If your child has asthma, please ensure they always have their inhaler in class)
*
Yes
No
I agree to inform Pole Attack Kids Ltd immediately if any of the above information changes to their medical information
*
Yes
Emergency Contacts
1st Emergency Contact Name
*
1st Emergency Contact Number
*
2nd Emergency Contact Name
*
2nd Emergency Contact Number
*
Parental Consent and Release
Disclaimer
I fully understand that my child is attending an aerial fitness related class and it is a 'high risk' form of exercise. Pole Attack Kids Ltd and our associated subcontractors, take no responsibilities for any injuries caused.
*
Yes
I understand that if there is any reason why Pole Attack Kids can not find a suitable cover instructor for a class which is the same discipline, we will put on a class on at the same time and day with an instructor of another discipline
*
Yes
I understand that if there is any reason why Pole Attack Kids are unable to run a class and find a suitable cover instructor, I will be offered a makeup session in another class, in exchange for the missed class.
*
Yes
I understand the 'Child' named above, must arrive on time for class. If they miss the warm up the teacher has permission to turn them away.
Yes
No unauthorised pictures or videos must be taken without our permission. All pictures and videos containing other children must not be uploaded to social media, without prior consent.
*
Yes
If your child receives an injury, relocates or anything else that stops them from attending their associated service with us. I understand that I will not be eligible for a refund, or a transfer.
*
Yes
I understand that from time to time, a qualified and insured instructor will physically spot to ensure the child is safe and understand what they are learning
*
Yes
I confirm I am the parent or legal guardian of the 'Child' (named above).
*
Yes
Name of Parent or legal guardian signing this form
First Name
Last Name
Signature
Thank you!!
Submit
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