Mexican Fiesta Program Registration | Deema Community Center

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Basic Information
Programme Enrollment
Medical Information

Mexican Fiesta Registration

Deema Programs - Mexican Fiesta - Cover 1500 x 785

Please submit the form complete & accurate for prompt processing. Note: Each registration form is ONLY valid for 1 member. Kindly complete a separate registration form for each member.

Member Information

First Name

Last Name

Phone

Email Address

Address

Date of Birth*

Date of Birth

Age*

Gender*

Male

Female

Parent/Guardian/Emergency Contact Information

Name

Phone

Relation

How did you hear about us?

Flyer

Referral

Online Search

Facebook

Instagram

Snap Chat

Walk In

Other

Write here

Have you called DEEMA COMMUNITY CENTER?

Yes

No

Deema Programs - Mexican Fiesta - Cover 1500 x 785

February 2020 - Click Here

Thursday Dates

6 February 2020

13 February 2020

20 February 2020

27 February 2020

March 2020 - Click Here

Thursday Dates

5 March 2020

12 March 2020

19 March 2020

26 March 2020

April 2020 - Click Here

Thursday Dates

2 April 2020

9 April 2020

16 April 2020

23 April 2020

30 April 2020

Consent

I give permission for pictures/videos to be take of my child.

I do not give permission for pictures/videos to be take of my child.

* Deema Community Center therefore reserve the right to notify parent/guardian prior to pre-schedule day/s where pictures/videos will be engaged, not to attend the facility on such given day/s and/or remove their child from the facility during such undertaking.

1. Are there any medical reasons/conditions which might prevent participant from partaking in any programmes?

Yes

No

If yes, please explain:

2. Does participant have any allergies?

Yes

No

If yes, please explain what causes have been identified with this/these allergy/ies:

3. Has participant had surgery in the last 12 months?

Yes

No

If yes, please explain:

4. Does the participant require any specialist support or assistance while participating in any of the programmes in the center?

Yes

No

If yes, please explain:

5. Does participant take any medications?

Yes

No

If yes, please name medication and condition taken for

IF YOU HAVE ANSWERED YES TO ANY OF THESE QUESTIONS, PLEASE CONSULT A PHYSICIAN PRIOR TO PARTICIPATING IN ANY ACTIVITY

Disclaimer

I understand this Medical History Questionnaire serves as a preliminary screening resource to assist our professionals in the determination of member risk to exercise and wellness programmes offered at Deema Community Center. If the participant is at risk and has not received medical clearance, I understand they cannot engage in any programmes on offer or receive recommendations from any staff member.

Participant/Guardian Name:*

Print Name

Date Time Title*

Select Date ×

Signature Pad Title

By submitting this form, you hereby agree to accept our Terms & Conditions. Your IP address 18.206.194.161 will be stored in our database.

Your form has been submitted

Thank you %NAME% for registering in our Biscuit Planet Program.
We have received your application and will contact you regarding additional information and payment options. You can view it anytime from this link below:
%TRACK_LINK%
We have also attached a copy of your submission.

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