Dancing Well with Parkinson's
Online Registration Form
Topic: Dancing Well with Parkinson's at Home Fridays 11am
Name
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First Name
Last Name
Email
*
example@example.com
Phone
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you / have you been involved in any exercise, movement or dance class; if yes, can you please briefly describe?
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Do you have any immediate health issues?
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How would you describe your general state of health?
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You acknowledge that your information will be held in accordance with DTI's Data Protection Policy (http://www.dancetheatreireland.com/pages/DataProtectionPolicy.htm) and that of eu.jotform.com.
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Yes
No
Like all physical activity, dance can involve risk of injury. Our classes are gently, but Dance Theatre of Ireland accepts no responsibility for injury or loss during your participation in classes. By registering for Well-Dance at Home you agree.
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Yes
No
Are you currently independently mobile?*
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Would you like to be contacted/receive email reminders and updates?
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Yes
No
Date of Birth or Age
*
How did you hear about this?
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Submit
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