Dana’s Dance


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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