How did you hear about us?

Facebook

Instagram

Google

5678 Friend

Parent/Guardian's Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student Name *

First Name

Last Name

Waiver/Release *

I/my child has permission to attend 5678 Dance’s Friend's Week. I/we realize that participation in dance classes and activities could involve some possible personal injury. Despite precautions, accidents and injuries may occur. By signing this release form, I/we (the child, adult student and or parent/guardian) assume all risks. The person participating in Friend's Week has up to date health insurance and, in case of an emergency, the 5678 Dance staff have my permission to authorize simple first aid and consent to any x-ray, exam and medical or surgical diagnosis that is deemed necessary in case of an emergency. Additionally, I/we hereby agree to individually provide for all possible future medical expenses, which may be incurred by myself or my child, as a result of any injury sustained while participating at 5678 Dance, Inc., School. I/we agree to release and hold harmless 5678 Dance, Inc., including its teachers, staff members, and facilities used by both entities from any cause of action, claims, or demands now and in the future. I/we will not hold 5678 Dance, Inc. liable for any personal injury or any personal property damage, which may occur on the premises before, during or after activities. Furthermore, I/we agree to obey the class and facility rules and take full responsibility for my/our behavior in addition to any damage I/we may cause to 5678 Dance, Inc. I understand that all images, photos and or videos taken by 5678 Dance, Inc., remain the exclusive property of 5678 Dance, Inc., and as such I/we unconditionally grant permission to 5678 Dance, Inc., to use said photos, images and or videos of myself or my child to print, promote, broadcast, advertise and or utilize on its website as 5678 Dance, Inc., and or its officers, managers, directors, employees, owners, at his / her / their / its sole discretion deems appropriate for the promotion of 5678 Dance, Inc.

Agree

Disagree (unable to participate)

Parent/Guardian Signature *

First Name

Last Name