Release of Claims and Authorization
I am aware that dancing and the physical movement associated with it places stress on the body and carries with it the risk of physical injury. On behalf of my child and myself (and if I am no longer a minor, on my behalf), I assume the risk and agree that J’adore Dance shall not be liable in any way for injuries sustained during attendance at J’adore Dance, it’s successors and it’s assignees for all personal injuries caused by, or arising from, the above described activities or any activities related thereto. I understand that, in order for all children enrolled in class receive the best dance education experience possible, J’adore Dance reserves the right to re-assess placement of any child who is not ready to participate productively and safely. Further I grant J’adore Dance, it’s agents and employees permission to authorize any emergency medical treatment that may be required for my child or ward during the 2017/2018-school session. My medical carrier is:
Student Name *
Student Name
Parent / Legal Guardian *
Parent / Legal Guardian
MM/DD/YYYY - MM/DD/YYYY
Release / authorization made on this date, April 25th, 2014 by the parent/ guardian listed above for the student listed above
I, the undersigned, have read this release/ authorization and understand all of its terms. I execute it voluntarily and with knowledge of its significance. I have executed this release/authorization on the day and year stated above
Signature of Student (if 18 years of age or older) / Signature of parent or Guardian. By Typing your First and Last name below you are agreeing and authenticating the information in this form.
Medical Information
Is the student allergic to anything (medication or other)? If yes please list: *
Does the student take any medication on a regular basis? If yes please list: *
Are there any medical conditions we should be aware of? If yes please list: *
Primary Care Physician’s Phone *
Primary Care Physician’s Phone
Emergency Contacts
If you would like to provide a contact other than the student’s parent/guardian, please list below:
Emergency Contact #1
Emergency Contact #1
Emergency Contact #1 Phone
Emergency Contact #1 Phone
Emergency Contact #2
Emergency Contact #2
Emergency Contact #2 Phone
Emergency Contact #2 Phone
Photograph Release
I, the parent/guardian listed above, (or student if 18+) authorize J’adore Dance and /or it’s representative agent, or employee to use any photograph/likeness of my child , listed above, (or myself) for any purpose, including publicity, choreographic archives, promotional materials and/or any other reason deemed appropriate by the artistic staff or marketing director.
Financial Agreement