Acrobatic & Tumbling Course September 2017 Application Form Please fill out this form and we will get in touch with you shortly. Name* First Last Date of birth** Male Female Please fill below* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Landline PhoneMobile Phone*Email* Website Please attach a photo of yourself.*Please provide Polichinelo Circus with a recent portrait photograph of yourself.Previous training (e.g. Dance, Gymnastics etc…)* Have you had previous experience (amateur or professional?)* Have you suffered an injury that might affect your training? please answer Yes or No If "YES" Please give details* Do you have any disabilities? for example hearing or speech problems?* No Yes If the answers of the question above was "YES" Please give details What are your expectations from the course?* How did you hear about the course?* MEDICAL HISTORY QUESTIONNAIREFor your application to be processed the medical history questionnaire must be completed in full.Emergency contactName* First Last Phone*Please provide details as requested. All information is confidential.Do you take any medication on a permanent/semi permanent basis?* No Yes If yes give reason Have you ever had an epileptic seizure?* No Yes If yes give date of last seizureHave you ever been treated for diabetes?* No Yes If yes what is your medicationHave you ever had high blood pressure?* No Yes Have you ever had a hernia?* No Yes Yes but it has been repaired Have you ever suffer from Asthma?* No Yes If yes what is your medicationHave you ever had concussion or any other head injury?* No Yes If yes please give detailsHave you ever had a neck injury?* No Yes If yes please give details Do you wear any dental appliances?* No Yes Are you pregnant?* No Yes Do you have any other medical condition we should be aware of?* No Yes If yes please give details * Please tick the box if you are the person named on the Application and that all the information given on the form is true and correct. You must be 16+ Years to attend this Course.