Enrol
m
ent
Form for Laura’s
Health
&
Dance
Fitness Children's classes.
Child's Name:
First Name
Last Name
Guardian's name
Email:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Eir Code
Contact Phone Number
-
Area Code
Phone Number
Child's Date of Birth
-
Month
-
Day
Year
Date
Does your child have any Learning Difficulties?
COVID-19 Questionnaire:In the last 14 days have you...1)Had any Covid-19 symptoms?2)Been in contact with any confirmed/ suspected Covid-19 cases?3)Have you recently travelled internationally?If you have answered 'YES' to any of the questions, please Do Not Attend any class and call your GP immediately !By Booking this class you are agreeing that you have answered 'NO' to all the questions above.
Date
-
Month
-
Day
Year
Date
Signature
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Submit
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