Dance for Parkinson's Australia                                Emergency Contact Information
Please fill out this form for participation in Dance for Parkinson's classes online zoom classes. This information helps us to keep in touch and to ensure best practice safety measures during classes. The information you provide on this form will be treated with the utmost confidentiality and will only be used to assist you in an emergency. For more information:

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Email *
Full Name *
Address: Please consider providing your address. An address can help us coordinate emergency services if needed. This address will not be shared and will only be used for emergencies.
Phone number *
Emergency contact full name *
Emergency contact phone number *
Emergency contact relationship to participant *
Disclaimer:   I hereby acknowledge that the information provided above, to the best of my knowledge, is correct.  I will inform the Instructor immediately if there are any changes to the above information.  I acknowledge that during physical activity classes, an accident may occur involving injury or damage.   I indemnify the Instructor and DPA  from all legal actions, injury claims, loss, damage, penalties and costs arising from my participation in this physical activity program. *
I agree to have my details held in the Dance for Parkinson's database for contact purposes and for disseminating information regarding the program *
Any additional comments or information- please use the space below?  We look forward to dancing together!  
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