Please list your 5678 Dance Friend who invited you:-)

First Name

Last Name

Student's Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Waiver/Release *

I realize that participation in dance/pilates classes and activities could involve some possible personal injury. Despite precautions, accidents and injuries may occur. By signing this release form, assume all risks. I have 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 hereby agree to individually provide for all possible future medical expenses, which may be incurred by myself, as a result of any injury sustained while participating at 5678 Dance, Inc., School. I 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 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 agree to obey the class and facility rules and take full responsibility for my behavior in addition to any damage I 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 unconditionally grant permission to 5678 Dance, Inc., to use said photos, images and or videos of myself 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)

Student Signature (Must be at least 18 to participate) *

First Name

Last Name