Dana’s Dance
Danasdancestudio.com
Student information and registration
Student Name__________________________________________________
Class Day and Time______________________________________
Birth Date_______________________________________________
Special Conditions we should know about? (Medical, allergies, etc.) ________________________________________________________________
Guardian Last Name_____________________ First___________________
Mailing Address_________________________________________________
City____________________________ Zip______________________________
Home Phone______________________ Cell_____________________
Work Phone___________________
Emergency Contact Name___________________________________
Emergency Contact Phone___________________________________
--Email is our primary contact media-- Email__________________________________________
Is registration fee of $15 paid? Circle one: yes no
How did you hear about us? ______________________________________________________
Waiver & Assumption of Risk:
I, as the adult student, OR parent/guardian of minor student(s), voluntarily make and grant this Waiver and Assumption of Risk to Dana’s Dance for the opportunity to use the facilities, equipment, materials, and/or other assets of Dana’s Dance and/or to receive assistance, training, guidance, tutelage, and/or instruction from the personnel of Dana’s Dance; and/or to engage in activities, events, sports, festivities and/or gatherings sponsored by Dana’s Dance: I do hereby waive and release any and all claims whether in contract or of personal injury, bodily injury, property damage, losses and/or death that may arise from my aforementioned use or receipt, as I understand and recognize that there are certain risks, dangers, and perils connected with such activity.. These dangers I fully understand and which I nevertheless accept assume and undertake after inquiry and investigation of extent, duration, and completeness wholly satisfactory and acceptable to me. I further agree to use my best judgment in undertaking these activities myself or in allowing my child to undertake these activities. I faithfully adhere to all safety instructions and recommendations, whether oral or written. I hereby certify that I am a competent adult assuming these risks for myself of my own free will or on behalf of my child(ren) being under no compulsion or duress. This Waiver and Assumption of Risks is effective, inclusive, and may not be revoked, altered, amended, rescinded, or voided without the express prior written consent to Dana’s Dance.
Will you allow pictures of yourself and/or your child(ren) to be taken and possibly circulated? Circle one: YES NO
Student/Parent Signature: __________________________________
Date: ________________
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