LMDS 10 - additional information form.

Name *
Name
Phone *
Phone
Address *
Address
Date of Birth *
Date of Birth
Phone *
Phone
Position *
Lamondance Jacket *
PLEASE EXPLAIN ANY “YES” ANSWERS BELOW. You are not obliged to disclose any personal information.
1. Have you had a medical illness or injury that has ever affected your dance training: Yes, no If yes, explain: Do you have an ongoing or chronic illness?
2. Are you currently taking any prescription or nonprescription (over the counter) medications or pills, or using an inhaler?
3. Do you have allergies (for example, to pollen, medicine, food, or stinging insects?) yes, no? if yes explain:
4. Have you ever had a head injury or concussion?
Yes no Have you ever had a seizure?
5. Have you ever had a sprain, strain, or swelling after injury?
6. Have you broken or fractured any bones or dislocated any joints?
7. Do you feel stressed out during dance activities?
8. Do you feel stressed out before performances?