The following information is needed by the dance department to permit us to be aware of the physical condition of your child in order to make necessary changes in his/her participation if necessary.
 

 

General Information First Name:   Last Name:   Grade Level: Please Select Senior Junior Sophmore Freshman Alpha: Address:   City: Zip:   Home Phone: Work/Cell:   Parent/Guardian's Full Name:     Parent/Guardian's Work Phone: Parent/Guardian's Cell Phone:  Home Email:     Medical History Medical conditions, medications, and or history which you feel medical personnel need to be aware of? (I.e. previous surgeries, chronic conditions, etc.)   Restricted Program (To be completed by a physician ONLY IF there are medical restrictions.)   Student Name:   Type of chronic health problems: Should not participate in the following type of activities: Physicians Signature: Date:   Complete application and return completed form to Ms. Koenke in the Dance Room