Recreational Registration

Student Information

How many students would you like to register?

Student Name:*

First Last

Date of Birth:*

Address:*

Street Address Address Line 2 City State ZIP Code

How many classes would you like to register for this student?

Class Selection:*

Student #2 information

Student 2 Name:*

First Last

Student 2 Date of Birth:*

How many classes would you like to register for student 2?

Student 2 Class Selection:*

Student #3 information

Student 3 Name:*

First Last

Student 3 Date of Birth:*

How many classes would you like to register for student 3?

Student 3 Class Selection:*

Student #4 information

Student 4 Name:*

First Last

Student 4 Date of Birth:*

How many classes would you like to register for student 4?

Student 4 Class Selection:*

Parent Information

Parent/Guardian Name:*

First Last

Parent/Guardian Home Phone:*

Parent/Guardian Mobile Phone:*

Parent/Guardian Email:*

Parent/Guardian 2 Name:

First Last

Parent/Guardian 2 Home Phone:

Parent/Guardian 2 Mobile Phone:

Parent/Guardian 2 Email:

Emergency Contact Information

Emergency Contact Name:*

First Last

Emergency Contact Phone:*

Emergency Contact Relationship to Student:*

Insurance Information

Medical Insurance Company:*

Medical Insurance Policy Number:*

Medical Insurance Policy Holder:*

Medical Insurance Group Number:*

Medical Insurance Phone Number:*

Physician Information

Physician Name:*

Physician Phone Number:*

Hospital of Choice:*

Waivers

Liability*

I agree to the waiver.

I, on behalf of myself or my minor child, AM AWARE THAT THESE ACTIVITIES ARE HAZARDOUS AND THAT I COULD BE SERIOUSLY INJURED OR EVEN KILLED. I AM VOLUNTARILY PARTICIPATING IN THESE ACTIVITIES WITH KNOWLEDGE OF THE DANGER(S) INVOLVED, AND AGREE TO ASSUME ANY AND ALL RISKS OF BODILY INJURY, DEATH OR PROPERTY DAMAGE, WHETHER THOSE RISKS ARE KNOWN OR UNKNOWN, INCLUDING EXPOSURE TO THE COVID-19 VIRUS.

I hereby assume all of the risks of participating in these activities, including, but not limited to, any risks associated with dangerous activities or any risks from equipment or property owned, maintained or controlled by Artistic Edge Dance Centre or because of injury/harm/damage that may arise from negligence on the part of Artistic Edge Dance Centre and/or the persons employed by Artistic Edge Dance Centre.

I certify that I or my minor child is physically fit, has sufficiently prepared or trained for participation in these activities, and has not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems that preclude my, or my minor child’s, participation in these activities.

I acknowledge that this Waiver and Release of Liability form will be used by Artistic Edge Dance Centre, the event holders, sponsors, and organizers of these activities in which I or my minor child may participate. I understand and acknowledge that this form will govern my, or my minor child’s actions and responsibilities throughout participation in any and all activities.

In consideration of my application, payment and participation in these activities, I hereby agree as follows:

A. I WAIVE, RELEASE, AND DISCHARGE Artistic Edge Dance Centre, any shareholders, owners, officers, members, employees, agents, successors or assigns (the “Released Party”), from any and all liability, including, but not limited to, liability arising from the negligence or fault of the Released Parties, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me in connection with, directly or indirectly, my participation in the event.

B. I EXPRESSLY RELEASE, HOLD HARMLESS, DISCHARGE AND INDEMNIFY (including costs and attorneys’ fees) the Released Parties from any and all liabilities or claims made for any accident, injury, illness, death, loss, damage to person or property, or other consequences suffered by me or any other person arising or resulting directly or indirectly from my participation in the event, whether caused by the negligence of the Released Parties or not. In the event that I am injured, I agree to assume any financial obligation, either through my personal health insurance, or through some other means, for any medical costs which I incur. Artistic Edge Dance Centre assumes no responsibility for any medical expenses, injury, or damage suffered by me in connection with the use of any facilities or services in connection with the participation in this event.

Physician Approval:*

I agree.

I have represented to Artistic Edge Dance Centre that I, or my minor child, has either a) been given a physician’s permission to participate in the event, or b) voluntarily participate in the event and accept all risks related to the event without the approval of my physician(s). I represent that I am not aware of any medical or physical condition that would prevent me or my minor child from participating in the event or from using equipment or facilities which pose a serious health risk to me or my minor child. I further acknowledge and agree that I or my minor child is not obligated to participate in any aspect of the event. I will inform Artistic Edge Dance Centre immediately if I or my minor child do not wish to participate in any specific activity within the event. In recognition of the danger, hazards and risks (foreseen and unforeseen) associated with attending and participating in the event, I confirm that I am physically and mentally capable of attendance and participation in all activities and use of all equipment associated with the event.

Medical Authorization:*

I agree.

I give permission for Artistic Edge Dance Centre, owners and employees, to seek emergency and medical treatment for the participant(s) in the event they are unable to reach any parent or guardian. The undersigned also agrees that they, themselves, will be responsible for any financial debt incurred by said action.

Concussion Awareness:*

I agree.

I understand the common signs, symptoms, and behaviors associated with head injury/concussion. If a concussion is suspected, my child must be removed from dance. It is my responsibility to seek medical treatment for my child. My child must not return to dance until providing written clearance from an appropriate healthcare provider.

Name and Likeness Release:*

I agree.

I hereby grant to Artistic Edge Dance Centre and its affiliates and assign Artistic Edge Dance Centre the right and permission to use in perpetuity, my name, likeness, image, voice, recorded voice, appearance, video, biographical information, performance and/or testimonial in any manner and in any media, now known or later developed, throughout the world at any time, for the purpose of advertising and publicizing Artistic Edge Dance Centre’s products and services, without review, permission or compensation of any amount or kind whatsoever. I hereby release Artistic Edge Dance Centre and its employees, photographers and videographers, from any and all claims or demands arising out of or in connection with said photographs or videos or the publications of said photographs or videos. This grant includes without limitation the right for Artistic Edge Dance Centre to edit, abridge, augment, title or create a compilation from my Appearance or part as Artistic Edge Dance Centre may elect in its sole discretion.

ACKNOWLEDGEMENT OF UNDERSTANDING: The participant has my permission to participate in Artistic Edge Dance Centre events and I warrant the below information is complete and correct. I have read the entirety of this Waiver and Release of Liability and I understand that I am giving up substantial rights, including my right or my minor child’s right to sue. I acknowledge that I am signing freely and voluntarily and intend, by my signature, that this document be a complete and unconditional release of liability to the greatest extent of the law. I further certify that I have fully read and understand the terms of this agreement and will comply with the contents herein.

Signature*

Total

$0.00

*Payment information will be emailed to the email address you provided.

Recreational Class Registration

Student Information

Student #2 information

Student #3 information

Student #4 information

Parent Information

Emergency Contact Information

Insurance Information

Physician Information

Waivers

Address

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