Medical Form – Dance Hub SA

October 17 X – Medical and Emergency Contact Form

The information on this form is kept confidential and will be destroyed after your contract with Dance Hub SA has been completed

Your Name *

First

Last

Date of Birth *//

Email *

Your GP's Name *

First

Last

Your GP's phone number: *

Please list any medical conditions / illnesses or allergies we should know for safety or emergency concerns *

e.g asthma, diabetes, epilepsy, allergies etc. If you do not have any please write none.

Please list any medications you are taking for these conditions. *

If not applicable please write none

Do you have any existing or pre-existing injuries that may affect your participation in X? *

Name *

First

Last

Mobile *

Relationship to you *