Dance for Parkinson's & Wellbeing - Registration & Medical information form

Payment & Declaration
Classes can cost between $0 and $25 each, depending if the program has received funding, or if you are a concession card holder.

Dance for Parkinson's & Wellbeing complies with the NDIS Code of Conduct and we offer the option of invoicing a dancer after each term of classes, otherwise classes are to be paid each week of attendance.

Cash is currently accepted each week, however, if enough people would like it we will evaluate an EFTPOS/Credit card option.
What method of payment would you prefer? *

Cash each class Eftpos/Credit card each class Invoiced at the end of each term Other
I am aware of the risks in observing or participating in the dance classes offered by Dance for Parkinson's & Wellbeing and I understand that all dance that I will participate in is entirely at my own risk. I understand that I must look after myself and my own health and safety and assume complete responsibility and liability for those risks and for the injuries that may occur as a result of these risks, even if injuries occur in a manner that is not foreseeable at the time I sign this agreement. I realize that by voluntarily assuming the risks involved, I will be solely responsible for any loss or damage I sustain, including personal injuries to me, damage to my property, or damage arising out of my death. It is understood that Dance for Parkinson's & Wellbeing is responsible for any damage that would be resulting from a fault of Dance for Parkinson's & Wellbeing and its representatives.
If you understand all you have read and declare it to be true and accurate, please sign and date below.

Typing your name is considered a signature
Signature *

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Date

Jour Mois Année
DD-MM-YYYY or click the calendar
hourhour:minuteminute Minutes AM/PM Option
Would you like a copy of the information you've submitted on this form? *

Yes No
To view our Privacy Policy please head to:

https://drive.google.com/open?id=1qWZAMV3zYmWNl1JVXNs3uEUhQm972fIC
If the dancer did not fill in this form personally, please provide the details of the person who did, in case of any need for clarification:

First Name Last Name
Phone Number
Should be Empty:

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	Yes	No	Describe/details please:
Back/spine problems
Shoulder problems
Heart condition
Sight/hearing problems
Arthritis
Anaphylaxis
High or low blood pressure
Parkinson's
Other

Registration form - Dance for Parkinson's & Wellbeing

Personal information

Health questions

Please note:

Payment & Declaration

If you understand all you have read and declare it to be true and accurate, please sign and date below.