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ULTIMATE DANCE ON THE MOVE- Liability waiver Please complete in order to be able to participate in events & classes at one of our locations. All students must have an updated liability waiver on file & if you are looking to schedule your child's introductory class please call and schedule it with the studio ahead of time as intro trial classes are not always available . (630)809-2010
Event:
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End Date/Time:
Fee per Student:
Room:
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- denotes required fields
Family Information
First Name:
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Last Name:
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Type
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Caregiver
Father
Guardian
Mother
Parent
Self
Home Phone:
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Cell #:
Work #:
Email:
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(Emails are kept confidential)
Address:
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City:
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State:
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Zip:
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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:
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Last Name:
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Student Gender:
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Female
Male
Birth Date:
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(format=mm/dd/yyyy)
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #2:
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Student's First Name:
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Last Name:
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Student Gender:
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Female
Male
Birth Date:
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(format=mm/dd/yyyy)
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #3:
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Student's First Name:
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Last Name:
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Student Gender:
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Female
Male
Birth Date:
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(format=mm/dd/yyyy)
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #4:
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Student's First Name:
*
Last Name:
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Student Gender:
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Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #5:
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Student's First Name:
*
Last Name:
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Student Gender:
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Female
Male
Birth Date:
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(format=mm/dd/yyyy)
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Questions/Options:
What event/class are you signing the liability waiver for?
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I understand that if my child has any medical needs or information that the studio should know that I will tell the staff at the event/class they attend so they are aware.
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Yes
No
I understand that if my child is attending a birthday party that it is a drop off party and I am welcome back 5 minutes before the end of the party to watch their dance they learned.
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Yes
No
Additional Information:
COVID Liability Release
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ASSUMPTION OF THE RISK AND WAIVER OF LIABILITY RELATING TO CORONAVIRUS/COVID-19: The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies have put in place recommended social distancing, occupancy restrictions and guidelines for businesses to follow. Ultimate Dance On The Move LLC has put in place preventative measures to reduce the spread of COVID-19; Ultimate Dance On The Move LLC will be implementing all recommendations from Illinois state officials as per Ultimate Dance On The Move’s Sanitation Practices & COVID procedures Guidelines document available on our website.
Ultimate Dance On The Move will make every effort to keep our studio sanitized and to prevent symptomatic employees and dancers from entering the building. However COVID-19 has been proven to be asymptomatic in some persons. Therefore, Ultimate Dance On The Move cannot guarantee that you or your child(ren) will not become infected with COVID-19 or any other unknown virus. Further, attending Ultimate Dance On The Move could increase your risk and your child(ren)'s risk of contracting COVID-19.
By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending Ultimate Dance On The Move and that such exposure or infection may result in personal injury, illness, permanent disability, and death. By signing this agreement, I agree that my child and any accompanying persons will not enter Ultimate Dance On The Move if we exhibit any of the following new or worsening signs or symptoms of possible COVID-19: A temperature greater than 100.4 degrees Fahrenheit, cough, shortness of breath or difficulty breathing, other respiratory symptoms, or at least two of the following symptoms: chills, repeated shaking with chills, muscle pain, sore throat or new loss of taste or smell. I also agree that, neither my child(ren) nor any accompanying adult will enterUltimate Dance On The Move if we have had known close contact with a person who is lab-confirmed to have COVID-19.
I've read the above and agree.
Liability Waiver
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As the legal parent or guardian, I release and hold harmless Ultimate Dance On The Move LLC, its owners and operators from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant while in or upon the premises or any premises under the control and supervision of Ultimate Dance On The Move LLC, its owners and operators or in route to or from any of said premises.
I 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 participant and parent/guardian) assume all risks related to the use of any and all spaces used by Ultimate Dance On The Move LLC.
I agree to release and hold Ultimate Dance On The Move LLC, including its teachers, dancers, 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 Ultimate Dance On The Move LLC liable for any personal injury or any personal property damage, which may occur on the premises before, during or after classes. Furthermore, I (and/or the Participant) 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 the facilities utilized by Ultimate Dance On The Move LLC.
I fully understand my right to review this Release and Waiver, and have carefully read and fully understand all the provisions of this Release and Waiver, and am freely, knowingly and voluntarily entering into this Release and Waiver.
I've read the above and agree.
Picture Release
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I give Ultimate Dance On The Move LLC my permission for the public display of pictures and or video of my child for possible advertisement purposes (i.e. brochures, newspaper ads, web site, etc. - no names will be used).
I fully understand my right to review this Release and Waiver, and have carefully read and fully understand all the provisions of this Release and Waiver, and am freely, knowingly and voluntarily entering into this Release and Waiver.
I've read the above and agree.
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