New Participant: Live, Laugh, Dance Registration

Dancer's Name

Parent/ Guardian's Name

Parent/ Guardian Address

City

State

Zip Code

Parent/ Guardian Email address

Parent/ Guardian Phone Number

Dancer's Birthdate

Dancer's Age (by June 2018)

Dancer's Sex

Emergency Contact (if different from Parent/ Guardian)

Emergency Contact Phone Number (if different from Parent/ Guardian)

Does the dancer have a tendency to overheat?

Does the dancer have atlantoaxial instability?

List of medications (if applicable)

Please describe the level of function of the participant in relation to physical activity.

Please describe any motivation techniques you would suggest.

Please describe techniques that could be used in the event of negative behavior.

Please note any other information you would like the dance instructors/volunteers to be aware of.

Dancer's T-shirt Size

Please check all dates that the dancer will miss due to further obligations.

Explanation for Participation & Evaluation:
Your son/daughter/guardian will be asked to perform certain procedures and tasks which will aid in the evaluation of fundamental motor skill, fitness, and swimming skills. This may include all or part of the following: weight, percent body fat, resting blood pressure, and measurements for flexibility and muscular strength, endurance measures, and skill testing. In some cases, your son/daughter/guardian will be asked to begin a certain work level and progress until he/she can no longer perform the test. Although he/she will be encouraged to perform to their best ability, we do not wish for anyone to perform these tests at a level which is abnormally uncomfortable. At any time, that all or any portion of the procedures described above may be terminated without penalty.

Risks and Discomforts
There exists the possibility of certain changes to occur during the tests and activities. They include abnormal blood pressure, fainting, disorders of heart beat, and in very rare instances, injury. Every effort will be made to minimize these by the preliminary screening and by observations during testing and activities. Emergency equipment and trained personnel are available to deal with these situations should they happen.

Benefits to be expected from participation
Many benefits may occur from your son/daughter/guardian's participation including: increased cardio respiratory capacity, improved skill level, opportunities for social interaction and enhancement, and incidental improvements from participation. Additionally, the clinic also provides parents/guardians to observe the activities and benefit from this observation.

Confidentiality
The information which is obtained during the laboratory evaluation of the Live Laugh Dance will be treated as privileged and confidential and will not be released without your consent. The information obtained, however, may be used for statistical or scientific purpose with your right to privacy retained. In addition, we asked that we be allowed to videotape and photograph your son/daughter/guardian for instructional purposes, research publications, social media, promotions, and marketing.

Freedom of Consent
If you have any doubts or questions, please do not hesitate to ask. Permission for your son/daughter/guardian's participation is voluntary. You are free to deny consent if you so desire or withdraw at any time.

I have read this form and understand the test procedures to be performed.

I consent to participate in the program.