Class Member Registration Form

Before taking part in a class, I will ask you to complete a class member registration form which you can read below.

I can either send you a form to complete, or fill the form in for you if you let me know your details and responses via your preferred method of communication.

If I send you a form, you can either send your completed version back for me to print off ready for you to sign at class, or you may print it off and bring it to class pre-signed. If I fill out a form for you, I will print it and bring it to class for you to sign. The transportation of forms to and/or from class is done so in a secure manner via the use of a file folder with a combination lock.


I ask class members to fill out these forms to help me provide a satisfactory service, ensure the safety of class members and because they are required for insurance purposes.

Forms are stored securely in my home office filling cabinet with photographic copies stored on my personal encrypted tablet, thus ensuring I have access to details in case of an emergency during a class. Contact numbers are added to my encrypted mobile phone and email addresses added to my email account.

Your forms and contact information will be stored for as long as you are attending a class. If you stop attending a class and don’t return within 6 months, your name will be taken off my personal class register and contact details deleted from my email account and mobile phone. Forms and their photographic copies are stored for 3 years and 4 months after you stop attending. After this time, your form will be shredded and its photographic copy deleted.

Personal information will only be shared with selected third parties in exceptional circumstances if requested with lawful basis for specified purposes. For more information on this and how I collect, store and use any information you choose to provide, please view my full privacy policy here You may request to see a paper copy.

*Name (+ name of Parent/Guardian if under 18): ­­­­­­­­­­­­­­­­­­­­

*Contact number:                                                                Email address (advised):

Emergency Contact (advised):

Name:                                                                                    Contact number:

I will only use the above information as a means of getting in touch with you if I have important class information/in case of emergency. I do not collect contact details for marketing purposes and you will not be added to any mailing list of any kind. Please inform me if any of your details change.


If you are between the ages of 15 and 69, this questionnaire will tell you if you should talk with your doctor before you take part in any classes. If you are over 69 years of age and not used to being very active, check with your doctor first. Common sense is your best guide when answering these questions.


Please read the questions carefully and answer each one honestly:

1. Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor? YES/NO

2. Do you suffer with any chest pain or tightness when performing physical activity? YES/NO

3. Do you suffer with any chest pain or tightness when not performing physical activity? YES/NO

4. Are you currently being prescribed medication by a doctor for blood pressure or a heart condition? YES/NO

5. Do you ever feel faint or have dizzy spells that cause you to lose balance or consciousness? YES/NO

6. Do you have a bone or joint problem that could be made worse by physical activity? YES/NO

7. Are you pregnant or have you had a baby in the last six months? YES/NO

8. Have you suffered any injuries recently that you have or have not recovered from? YES/NO

9. Have you had any surgery recently? YES/NO

10. Are you currently taking any medication you feel I should be made aware of? YES/NO

Please state:

11. Do you have any medical conditions you feel I should be made aware of? YES/NO

Please state:

12. Are you aware of other reasons why you should not participate in physical activity? YES/NO


If you have answered yes to any of the above questions – I strongly suggest that you seek professional medical advice before taking part in a class. Tell your doctor about the PAR-Q and which condition you are concerned about. You may be fine to take part in my classes as long as you start slowly and build up gradually. Talk with your doctor about wanting to participate in my classes and follow his/her advice.

If you answered no to all the above questions – You can be reasonably sure that it is suitable for you to take part in my classes. Just begin slowly and build up gradually.

All types of exercise carry an element of risk, dance is no different! My classes are designed to minimise risk whilst providing effective dance-based workouts!

If at any point during a class, you become unwell, feel undue pain, excessive discomfort or experience any unusual symptoms, stop immediately and inform me of your symptoms. Likewise, if at any point you become concerned with the safety of the class environment, please stop and inform me. You are free to withdraw from participating at any time you wish.

I ask you to take my classes at your own pace and only do what you feel is comfortable. If you need to take a rest, miss moves out or tailor moves to your ability, please feel free to do so and act as you see fit. I endeavour to provide alternative options during routines wherever I can.


I accept that I am taking part in the classes voluntarily and at my own risk. I have been made aware of the nature of the classes and the risks involved. I understand that I may withdraw at any time. I hereby confirm that I am voluntarily engaging in an acceptable level of exercise which is within my capability:

I have read, understood and answered all the questions in the PAR Q to the best of my knowledge:

I have sought any medical advice that has been advised:

If any unusual pain or symptoms occur during a class, I will stop immediately and inform the teacher. If my health changes therefore prompting a YES response to any of the PAR Q questions, I agree to update the teacher immediately, cease participation and consult with a medical professional before continuing with any classes:

I agree to stop participating and inform the teacher if I am ever concerned with the safety of my class environment:

Print name (+ Name of Parent/Guardian if applicable):


(or Signature of Parent/Guardian if applicable)


I will ask you to undertake a new PAR Q and check your details annually.