McGinley School of Irish Dance

Last Name

First Name

Medical Form 2007-08

Dancer's Name

Age

Birthday

Allergies

Asthma? Use of Inhaler?

Any Chronic Illness?

Any Previous Injuries? When?

Insurance Company

Policy Number

Name of Policy Holder

In case of emergency, please contact

Relationship to Dancer

Phone Number

Parent's Signature: _______________________________________

Date: ______________________

Revised: July 09, 2007