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