Come Try a Dance Class for Free! Classical Ballet Format.
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Fee per Family: 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*
Additional Information:

As legal guardian of the above named persons, I RECOGNIZE AND FULLY UNDERSTAND THAT POTENTIALLY SEVERE INJURIES, INCLUDING PERMANENT PARALYSIS OR DEATH can occur in activities involving physical activity. BEING FULLY AWARE of these dangers and in consideration of the minor being permitted to participate in activities at this facility, I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I, or my child, incur as a result of my child’s participation in the activities at this facility. I HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE, AND AGREE TO INDEMNIFYAND SAVE AND HOLD HARMLESS Elite Academy of Dance and Performing Arts, LLC. on my own behalf and the behalf of my child and our representative heirs, administrators, executors, and successors, its officers, directors, shareholders, employees or other representatives, whether paid or volunteer, FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES, WITHOUT LIMITATIONS, ON THE MINOR’S ACCOUNT OR MINE caused or alleged to be caused in whole or in part by the negligence of Elite Academy of Dance and Performing Arts, LLC. its officers, directors, shareholders, employees or agents.
I have read and understand, and will at all times, abide by and have my child abide by rules, regulations and policies as set forth by ELITE ACADEMY OF DANCE AND PERFORMING ARTS, LLC.

SIGNATURE:_______________________________DATE SIGNED:__________ RELATION TO STUDENT(S):_____________

PERMISSION FOR EMERGENCY MEDICAL TREATMENT/MEDICAL INSURANCE My signature below indicates that I have medical coverage on the student(s) listed above and will maintain continuous medical coverage during the time that he/she is a participant at Elite Academy of Dance and Performing Arts LLC. I hereby authorize Elite Academy of Dance and Performing Arts LLC, its members, owners, directors, and/or employees to administer simple first aid procedures to/on the student(s) listed above and to consent to any other medical procedure(s) including x-ray, exam, and medical or surgical diagnosis that is deemed necessary in the case of an emergency and RELEASE, DISCHARGE AND COVENANT NOT TO SUE for any negligent medical efforts expended on my behalf or on behalf of the minor. Additionally, I hereby agree to individually provide for all possible future medical expenses which may be incurred by my child as a result of an injury sustained while participating at or for Elite Academy of Dance & Performing Arts, LLC. I certify that I personally and/or my medical insurance carrier will be responsible for ALL expenses which are incurred in relation to any injury sustained during any related activity, including, but not limited to: classes, rehearsals, performances, studio activities, etc.

SIGNATURE:_______________________________________ Date Signed:____________ Relation To Student(s)____________
Special Medical Conditions:_______________________________________________________________________
Pediatrician/Doctor:_________________________________________ Phone#:_______________________________________
Emergency Contact:_____________________________ Phone Number(s):_______________Relationship:_________________

PHOTOGRAPHS AND/OR VIDEO RELEASE I hereby give my permission to Elite Academy of Dance and Performing Arts, LLC, for appropriate use of photographs of the student listed above for Elite Academy of Dance and Performing Arts, LLC website, photo galleries, program books, promotional offers (fliers, mailing, etc.) or other related activities.
SIGNATURE:________________________________________ Date:___________ Relation To Student(s):__________________

I've read the above and agree.
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