ROSIE RAINBOW
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Student PAR-Q - Under 16
*
Indicates required field
Student's Full Name
*
First
Last
Name of Parent / Guardian
*
Date of Birth
*
Relationship to Young Person
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Gender
*
Email
*
Phone Number
*
Emergency Contact
*
Secondary Emergency Contact
*
Emergency Contact Phone Number
*
Secondary Emergency Contact Phone Number
*
Please confirm that you agree to be added to Rosie Rainbow Circus' newsletter mailing list in relation to offers / events / information
*
YES I'd love to know what's happening
NO I do not want to be updated
Medical Questionnaire - Does your child have or have they ever experienced any of the following? Please tick if yes.
*
Do you have any allergies?
High / low blood pressure
Dizziness or shortness of breath when exercising
Diabetes
Chest pains bought on by physical exertion
Anxiety / panic attacks
Epilepsy
Are you on any medications?
Dizziness / Fainting
Asthma or respiratory problems
Bone, joint or muscular problems
Do you have any illness or disability which would limit your taking part in physical activity?
Sustained injury or illness
Any operations
Do you have any injuries Rosie Rainbow or other instructors should be aware of or that may prevent you from taking part? Do you have any injuries that may be aggravated by taking part?
Do you have any transmittable or blood diseases?
Has a doctor or other health care professional advised your child not to participate in physical activity?
Do you know of any other reason why your child should not take part in physical activity?
None of the above apply to my child
Please check the box next to the question if you answer "yes" to any of the following questions
If you have ticked "Yes" for any of the questions on the medical questionnaire, please provide further details here.
*
Has your child ever taken part in a similar class before?
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Yes
No
If they have taken part in similar classes before, please state the level of achievement
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Is there a particular skill or piece of equipment that they enjoyed the most? Is there anything they'd like Rosie or other instructors to know?
*
Does your child regularly exercise?
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Yes
No
What kind of exercise do they enjoy?
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What does an average week's exercise look like at the moment?
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IMPORTANT : Is there anything else we should know about your child that has not been addressed in the questions on this form?
*
I confirm that I have disclosed all medical conditions to Rosie Rainbow Circus and any instructors working for her and that, where relevant, the student will carry personal medical equipment at all times (e.g. epi-pen, inhalers, etc...)
*
Yes
No
Standard Informed Consent - Please tick to confirm that you have read and accepted each statement.
*
In the absence of a parent / guardian I understand my child is responsible for monitoring themselves throughout any activity and should any injury occur, they would cease participation and inform the instructor.
All children must work within their own capabilities and listen to instruction at all times.
Circus skills can be physically challenging and minor bumps, bruises and scrapes are common.
The instructor will from time to time need to touch your child for spotting, posture, alignment, correction, positioning and safety purposes. Please indicate in the box below and ensure you discuss with the instructor if you feel your child has any additional sensory or safety needs regarding physical touch.
Please ensure your child is on time for class and stays until the end of the session in order to benefit from the warm up and cool down which are essential to avoid muscle strains and stiffness.
In the event that medical clearance must be obtained before my child's participation in a session, I agree to contact the GP and obtain permission prior to the commencement of the exercise activity.
I understand that if my child fails to behave in a manner that is polite and social, they could be suspended from that particular activity.
If your child has any known allergies, epilepsy or asthma you must make the instructor in charge of the session aware of any medication they are taking and where to find it.
Video / Photography Consent
*
I give permission for photographs and videos to be taken and published in the private Facebook group for members of my class & their families.
I give permission for my child to appear in promotional photography / video clips of Rosie Rainbow Circus / Rainbow Circus Co sessions. This material may be used on the website, Facebook, Instagram or on other promotional media
I acknowledge that if consent is not given on the previous two optionsI must remember to communicate this to the instructor at the start of classes to ensure my child's privacy
.
*
In completing this form, I the parent / guardian of the aforementioned child, affirm that I have read this form in it's entirety; I have answered the questions accurately and to the best of my knowledge and will inform Rosie Rainbow Circus / Rainbow Circus Co in writing of any future changes.
.
*
I the parent / guardian of the aforementioned child give permission for them to participate in Rosie Rainbow Circus / Rainbow Circus Co sessions and understand that the Instructor(s) leading the class cannot be held liable for any loss or personal injury.
Submit
Home
Circus & Aerial Tuition
In Person Tuition
Online Tuition
Entertainment
Circus Workshops
Stilt Walking
Fire Performance
Aerial Performance
Birthday Parties
Morwenna the Mermaid
Large - Scale Events
Rainbow.Circus.CIO
Rainbow Circus CIO Testimonials
Zombie Crawl 2024
Unbroken Circus
Testimonials
Contact
Contact
Gallery