Registration Form for over 16’s

Forename (s) (required)

Surname (required)

Date of Birth (required)

Address (required)

Post Code (required)

Tel (Home)

Tel (Mobile) (required)

Email Address (required)

How can we contact you (select for yes) (required)
 May we contact you by post? May we contact you by email?

How did you hear about Pure Dance?

Health Declaration
I hereby vouch that the above-named participant is in a satisfactory state of health. You should however be aware of the following conditions:

Special Medical Conditions: (Please list e.g asthma, diabetes, epilepsy etc.)

Special Medication being taken: (Please list)

In Case of Emergency who would we contact?

Name:

Relationship to the participant:

Contact no.:

Media Release Consent
Occasionally we may like to photograph classes for our records and for future publicity, both printed and online. By signing below you are agreeing to Pure Dance using photographs in publications, online, in publicity material and for inclusion in the Pure Dance image library.

I can confirm that I have read and accept the above Terms and Conditions
 Yes

Signature:
You can use your mouse cursor or your finger if you have a touch screen.
Signature below

Print Name:

Date:

Thank you for completing this form. All information is confidential and will not be passed on to third parties.