Registration
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Event:
Start Date/Time:
End Date/Time:
Fee per Student:
Room:
*
- denotes required fields
Family Information
First Name:
*
Last Name:
*
Type
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Caregiver
Father
Grandparent
Guardian
Mother
Parent
Self
Home Phone:
Cell #:
Work #:
Email:
*
(Emails are kept confidential)
Address:
*
City:
*
State:
*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
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MO
MS
MT
NE
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NH
NJ
NM
NY
NV
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
*
Emergency Name & Phone Number (Not Primary Contact)
*
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)
Student Email:
School:
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:
*
Last Name:
*
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
Disabilities ( Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #3:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
Disabilities ( Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #4:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
Disabilities ( Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #5:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
Disabilities ( Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Additional Information:
Release of Liability
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I agree to release, waive, discharge and hold harmless Avanti Dance Company (also hereby referred to as ADC) from any and all liabilities, claims, losses, demands, or causes of action, except in the event of gross negligence by Avanti Dance Company, that may arise from or be related to any loss, damage, accident, illness, or injury, including death, which may be sustained by Student or Student's personal property while participating in dance/aerial training/acro/tumbling instruction whether on the ADC premises or off-the premises such as at ADC performances, productions, dance recitals, competitions and/or any other event organized by ADC. The undersigned agrees and acknowledges that voluntary use of Avanti Dance Company's facilities and services, and participation in the "ADC" programs, may involve inherent danger and risk, including, without limitation, the risk of physical illness or injury, death or property damage. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR, AND RISK OF ILLNESS, BODILY INJURY, DEATH OR PROPERTY DAMAGE to the undersigned or such participating children due to negligence, active or passive, or otherwise while in, about or upon the premises of the ADC and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with "ADC", the undersigned acknowledges that any illness or injuries that the undersigned or such participating children contract or sustain may be compounded by negligent first aid or emergency response of the RELEASEES and WAIVE any claim in respect thereof. THE UNDERSIGNED further expressly agrees that the foregoing ASSUMPTION OF RISK, RELEASE AND WAIVER OF LIABILITY, AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the laws of the County of Orange and the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
I've read the above and agree.
Assumption of Risk
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I understand that dance, aerial arts and/or acro-tumbling instruction/performance may include, without limitation, dancing with props, stretching, barre work, across the floor combinations, choreography work, aerial apparatus (silks or hoop) suspended above the ground, floor gymnastics and other related activities. I further understand that if I and/or my child are participating in any or all of the activities of dance, tumbling/acro and aerial instruction and/or subsequent performance such activities involve some degree of risk of strain or bodily injury. THE UNDERSIGNED, ON HIS OR HER BEHALF AND ON BEHALF OF HIS/HER SUCH PARTICIPATING CHILD, HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE, AND AGREES TO INDEMNIFY AND HOLD HARMLESS Avanti Dance Company (hereinafter referred to as ADC) its directors, officers, employees, renters, contractors, volunteers and agents from all liability to the undersigned or such participating children and all personal representatives, assigns, heirs, and next of kin of the undersigned or such participating children for any loss, liability, damages or costs they may incur, whether caused by the negligence, active or passive, or otherwise while the undersigned or any participating child is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with Avanti Dance Company and any claim or demands on account of any property damage or any injury to, or an illness or the death of, the undersigned or such participating children directly or indirectly, from the undersigned or such participating children whether caused by the negligence, active or passive, of "ADC" or otherwise while the undersigned or such participating children are in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with "ADC". The undersigned expressly and knowingly waives all rights under California law.
I've read the above and agree.
Medical Emergency
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Avanti Dance Company does not carry medical insurance for its students. It is required that all students be covered by their own individual/family insurance policies and if injury occurs it is understood that the student's own policy is the only source of reimbursement. I hereby acknowledge that I have read the statements above and agree to the terms as stated herein. Consent to Medical Treatment of Minor: In checking the box, I, (Parent) give the ADC staff permission treat a minor injury sustained by the student (minor child), or for any treatment which is deemed necessary by emergency medical personnel if called by the ADC staff, if in the event of an accident or injury to a student (minor child) if ADC is unable to reach me (Parent). I, Parent, hereby acknowledge that I have read the statement above and consent to the medical treatment of a minor. The undersigned agrees and acknowledges that use of "ADC" facilities and services, and participation in the "ADC" programs, may involve inherent danger and risk, including, without limitation, the risk of physical illness or injury, death or property damage. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR, AND RISK OF ILLNESS, BODILY INJURY, DEATH OR PROPERTY DAMAGE to the undersigned or such participating children due to negligence, active or passive, or otherwise while in, about or upon the premises of the ADC and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with "ADC", the undersigned acknowledges that any illness or injuries that the undersigned or such participating children contract or sustain may be compounded by negligent first aid or emergency response of the RELEASEES and WAIVE any claim in respect thereof.
I've read the above and agree.
Photo/Video Waiver
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I, the Student/Parent, understand ADC may photograph/video the Student (minor child) related to his/her training, performances and/or ADC events and/or may post photos/videos which are of a promotional nature on the ADC website or ADC related social media accounts. I hereby acknowledge that I have read the statement above and specifically authorize photography/video the student pertaining to the student's dance training/performances/events by ADC and allow ADC post any related photos/videos to social media accordingly. I understand that if I do not wish for the student (minor child) to participate in any photography/videography pertaining to the student's training/performances/events by ADC nor the posting of any related photos/videos to social media, that I must provide written notice to the ADC administrative staff prior to enrolling the student in any classes or taking any classes at Avanti Dance Company.
I've read the above and agree.
Enter your Full Name:
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Other Questions/Comments:
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