Registration

Registration

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Event:

Start Date/Time:

End Date/Time:

Fee per Student:

Room:

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Family Information

	First Name:*	Last Name: *
	Home Phone:	Cell #: Work #:
	Email:	(Emails are kept confidential)

	Address: *
	City: *	State: * Zip: *
	Emergency Contact Info (Not Contact #1 or #2)

Students entered below will be added to your family's account

Add New Student #1:

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	Student's First Name: *	Last Name: *
	Birth Date: *	(format=mm/dd/yyyy)
	Grade Level:
	Disabilities (Leave blank if NONE):
	Allergies (Leave blank if NONE):

Additional Information:

Assumption Of Risk

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I've read the above and agree.

Release of Liability

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I've read the above and agree.

Medical Emergencies

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Multimedia Policy

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COVID-19 Release

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- I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show any signs or symptoms and still be highly contagious. I understand The Dance Kollective, LLC will take all precautions suggested with COVID-19 prevention, but it is impossible to determine who has it and who does not given the current limitations in virus testing.
- I understand that should I be diagnosed to be COVID-19 positive within 14 days following our time at The Dance Kollective, LLC I will contact Kim Bertrand to let her know of my positive diagnosis.
- I release Kim & Paul Bertrand, The Dance Kollective, LLC and all teachers and staff members from any and all liability associated with receiving a COVID-19 positive diagnosis.??
- I confirm that I am not, nor is anyone living in my home, presenting any symptoms of COVID-19, including, but not limited to, fever, shortness of breath, dry cough, runny nose, sore throat. ??
- Should I or anyone living in my home present with any COVID-19 symptoms, 14 days prior up to the day of my dance class or lesson, I will contact The Dance Kollective, LLC and cancel my class or lesson.??
- I understand that The Dance Kollective, LLC reserves the right to cancel or reschedule any class or lesson at any point in time due to COVID-19 implemented regulations, health concerns, possible exposure, or arising symptoms of COVID-19.??
- Although exposure is unlikely, by signing this agreement, you accept the risk and consent to participation for classes, lessons and events at The Dance Kollective, LLC,
- You agree to adhere to all safety guidelines and measures set forth by The Dance Kollective, LLC to help stop the transmission of COVID-19.

I, for myself and on behalf of my heirs, assigns, personal representatives, and next of kin hereby release and hold harmless The Dance Kollective, LLC, their officers, agents, officials, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event ("Releasees"), WITH RESPECT TO ANY AND ALL ILLNESS, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF RELEASES OR OTHERWISE, to the fullest extent permitted by law.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

I've read the above and agree.

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Additional Info

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Your Account Name:

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Your Account Type:

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