Shannon's Fitness and Dance Child Training Application
Child's Name *
Date
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Address
Organization
Phone Number
Date of Birth
MM
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DD
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YYYY
Parent/Guardian Name
Parent/Guardian Address
Parent/Guardian Home Phone Number
Parent/Guardian Cell Phone Number
Parent/Guardian Email Address
Relationship to the Child
Child Physician's Name
Child Physician's Phone Number
Emergency Contact Name
Emergency Contact Phone Number
Relationship to Child
Is texting okay?
Clear selection
Does your child have allergies?
Clear selection
If so, what are the known allergies?
What medications is your child taking?
Does your child experience high blood pressure?
Clear selection
Does your child experience seizures? If so, how often?
Does your child suffer from any known cardiopulmonary problems?
Has your child had any broken bones in the past two years?
Has your child had surgeries or medical complications in the past 5 years?
Are there any known contraindications to exercise/ physical exertion?
Limitations to Stretching: (please check all that apply)
Is there any limitations to any Muscle strength activation movements?: (please check all that apply)
What would you like us to know about your child?
Are there any limitations that you would like to express about your child?
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