Dance for Parkinson's & Wellbeing - Registration & Medical information form
Language
  • Français
  • English (US)

  • Registration form - Dance for Parkinson's & Wellbeing

    You must complete this form to be able to participate in classes, if you prefer there is a paper copy of this form you may fill in. To view our Privacy policy please head to: https://drive.google.com/open?id=1qWZAMV3zYmWNl1JVXNs3uEUhQm972fIC
  • Which class will you primarily be attending?*
  • Are you planning to participate primarily:*
  • The Westside class will be live streamed via Zoom in Term 2 2021, would you like assistance to get set up with Zoom?

  • Personal information

  • Date of Birth*
     - -
  • Would you like your birthDAY (not year or age) recognised in class?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Is the address you provided above the only address you will be undertaking online classes from?*

  • Health questions

  • Common sense is your best guide when you answer this questionnaire. Please read the questions carefully and answer each one honestly: check YES or NO and add information if the answer is Yes

  • Rows
  • Consent to medical attention - please select if you agree

  • If there are any changes to an existing medical condition, please inform your teacher as soon as you can.

    ---------------------------------------------------

  • Do you ever have trouble getting into or out of a:*
  • Do you need assistance to participate in a seated to standing dance class?*
  • If you answered Yes or Maybe, do you have a carer/family member/friend who can attend class with you to assist you?

  • Please note:

    Dance classes can involve risk of personal injury. While teachers take all reasonable care in the conduct of classes; they accept no responsibility for injury or loss caused during classes or whilst participants are at or near the dance space. You are responsible for ensuring that you are physically and mentally fit for the class, and during the class you must at all times take care of your own personal safety.

  • 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?*

  • 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
  • Date
     - -
  • Would you like a copy of the information you've submitted on this form?*

  • To view our Privacy Policy please head to:

    https://drive.google.com/open?id=1qWZAMV3zYmWNl1JVXNs3uEUhQm972fIC

  • Format: (000) 000-0000.
  • Should be Empty: