Name *

First Name

Last Name

Have you ever been advised by your doctor that you have a heart condition and should only do physical activity recommended by a doctor? *

Yes

No

Do you ever feel pain in your heart or chest when you do physical activity? *

Yes

No

Have you ever had chest pain when you were not doing physical activity? *

Yes

No

Do you ever feel faint or have spells of dizziness? *

Yes

No

Do you have a bone or joint problem that could be made worse by exercise? *

Yes

No

Have you ever been told you have high blood pressure? *

Yes

No

Are you currently taking any medication? *

Yes

No

Are you pregnant or have you had a baby in the last 6 months? *

Yes

No

Is there any other reason you should not participate in physical activity? *

Yes

No

Confirmation *

I confirm that I have completed the above questionnaire to the best of my ability and that I have provided accurate information regarding my current health status. I take it upon myself to discuss any changes in my health with the teacher and my doctor. I understand that any dance/exercise class has certain risks and that the degree of risk depends on my health and physical fitness. I am voluntarily participating in the class/lesson with Burroughs Dance Centre and will immediately discontinue any activity if I feel any symptoms of distress or discomfort, and will notify the teacher.

Personal Data *

I give permission for Burroughs Dance Centre to store and handle my personal data in accordance with the school’s privacy policy and General Data Protection Regulations.

Coronavirus *

I confirm that I am following all Government advice in regard to Coronavirus.