Académique Documents
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Space is limited so complete and return the attached registration as soon as possible.
For more information contact Kellie Lightfoot, PT, at 330-543-4272 or KLightfoot@chmca.org
Dance Unlimited
Registration Form
Child/patients name: _________________________________________________________
Childs age: ______________________
Childs diagnosis: ___________________________________________________________
Parents name: _____________________________________________________________
Phone: ________________________________
Address:___________________________________________________________________
City, State, Zip Code:_________________________________________________________
Email Address: ___________________________________________
Medical History: _____________________________________________________________
__________________________________________________________________________
Surgical History: ____________________________________________________________
__________________________________________________________________________
Any sensitivity to sound or touch? _______________________________________________
Any precautions for physical activity? ___________________________________________
Which class time do you prefer: 4:15-5:15
or
5:15-6:15________________________