Weekly classes of DISCO, TAP and ZUMBA in Upminster are no longer running due to relocation (Sept 2024).

There will however be Dance Events coming up in the near future, book your first event class....Disco 11th October 2024 7.30pm.

FRIDAY - Adults DISCO Event 7.30pm
OCTOBER 2024
11th

CONTACT DETAILS
Full Name (required)

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Mobile Number (required)

If this is your first time attending one of Occasional Dance classes please complete the following health questionnaire and consent form.
If you have attended in the past scroll directly Payment Options.

MEDICAL HISTORY

Tick yes or no. If you tick ‘yes’ to any of the below you may need your doctors’ consent before you participate.
1. Have you ever suffered with epilepsy? YesNo
2. Are you pregnant? YesNo
3. Has a doctor ever said that you have a heart condition and not to take part in physical activity? YesNo
4. Has a doctor ever recommended medication for your blood pressure or a heart condition? YesNo
5. Do you have chest pain brought on by physical activity? YesNo
6. Have you developed chest pain in the last month? YesNo
7. Are you presently taking any form of medication? YesNo
If YES please list:
MEDICATION

8. Do you ever have spells of dizziness or feel faint? YesNo
9. Have you ever had either high or low blood pressure, and/or high cholesterol? YesNo
10. Have you ever had asthma, chronic bronchitis or any other chest ailments? YesNo
11. Do you suffer from severe back pains or any orthopaedic problem? YesNo
12. Do you have a bone or joint problem that could be aggravated by physical activity? YesNo
13. Do you suffer from severe headaches or migraines? YesNo
14. Are you recovering from a recent illness / operation or injury? YesNo
15. Have you any medical condition that we should be aware of? YesNo
If YES please list:
MEDICAL CONDITIONS

16. Is there any history of heart disease in your immediate family (before age 55)? YesNo
17. Are you aware through your own experience or from doctors’ advice of any other reason.
why you should not do physical activity without medical supervision? YesNo

PLEASE NOTE: If you have answered YES to any questions 1-17, you are advised to seek medical advice/approval before taking part in this class.

18. Any known allergies? YesNo. If YES please list

ALLERGIES

DATE OF BIRTH

EMERGENCY CONTACT NUMBER

INFORMED CONSENT
I realise that my body’s reaction to physical activity is not totally predictable. Should I develop a condition that affects my ability to exercise, I will inform my instructor immediately and stop exercising if necessary. I take full responsibility for monitoring my own physical condition at all times. I, the undersigned, recognize that it is my responsibility to notify my teacher of any serious illness or injury before the fitness class.

If you have answered ‘YES’ to any of the above questions, are pregnant, have a history of heart disease or suffer from any other medical condition, we strongly recommend that you obtain your doctor’s consent that you many take part in this class/training event.

In consideration of being permitted to participate in class, I agree to assume full responsibility for any risks, injuries or damages, know or unknown, which I might incur as a result of participating in the class and Tina Easteal/Occasional Dance will not be responsible for any injury or loss or harm of any kind that may result directly or indirectly from myself the undersigned taking part in this class.
Agree

PAYMENT (required)
Bacs payment will be required for your class, bank details will be sent to you.

How did you hear about the class? (required)

I agree to being contacted by Occasional Dance in relation to my enquiry/booking/updates please tick yes or no (required)
YesNo