Spring Fling! Registration & Screening Form

Spring Fling! Registration & Screening Form

Beginner ballroom dance for all levels
Rachel Balaban

has been teaching dance for more than 15 years, dedicating her career to teaching movement to people with neurological disorders, specifically Parkinson’s Disease and Autism. She is committed to helping people access their vitality and health through the use of their own bodies and to make dance accessible to all populations. She is a Teaching Associate in the Brown University Medical School and is a former dancer and Board President at Newport Contemporary Ballet.
Gregory Tyndall

trained formally in dance at the Cobb County Centre for Performing Arts at Pebblebrook High School. He has also trained at the Atlanta Ballet, Kirov Academy, Rock School for Dance Education, Nashville Ballet, and the Cincinnati Ballet. He earned his BFA from the Indiana University Jacobs School of Music Ballet Theatre and has been a dancer with Newport Contemporary Ballet since 2018.
Part 1. Contact Details
Full Name*

First NameLast Name
Phone Number
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E-mail*
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Emergency Contact Person/Relationship*
Emergency Contact Person/Relationship
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Emergency Contact Number
Part 2. Personal Measurements
Sex

MaleFemale
Age*
Part 4. Medical History
Have you ever suffered from...?*

AsthmaHigh or Low Blood PressureEpilepsyDiabetesDizziness or FaintingHeart DiseaseShortness of breathHigh CholesterolHeadaches or MigrainesNONE
If yes, please describe:
Do you have any allergies (e.g: food, environmental, medications)?*

YesNo
If yes, please describe:
Do you experience any pain or discomfort during physical activity?*

YesNo
If yes, please describe:
Do you have any physical or mobility needs (e.g., wheelchair, crutches, prosthetics, etc.)*

YesNo
If YES, please describe...
Do you have a history of injuries? (e.g., joint, muscles, etc.)?*

YesNo
If YES, Details...
Dance Experience & Preferences:
Have you participated in any dance classes or activities before?*

YesNo
If YES, please describe
Do you have any preferences for the pace or style of the class (e.g., slower pace, more verbal instructions, adaptive movements)?*

YesNo
If yes, please describe:
Are there any particular accommodations or support needs that would help you feel more comfortable and included in the class?*

YesNo
Consent & Acknowledgement:
I consent to the use of photos/videos taken during the class for promotional purposes.*

YesNo
By signing below, I acknowledge that I have provided accurate information and understand that the instructors will use this information to create an appropriate and inclusive environment. I understand that it is my responsibility to inform the instructor of any changes in my health or needs during the course of the class.
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Following the submission of this form a payment link of $20 per ticket will be sent to you from Jordan for the registration fee for this class.
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Spring Fling! Registration & Screening Form

Rachel Balaban

Gregory Tyndall

Part 1. Contact Details

Part 2. Personal Measurements

Part 4. Medical History

Dance Experience & Preferences:

Consent & Acknowledgement:

Following the submission of this form a payment link of $20 per ticket will be sent to you from Jordan for the registration fee for this class.