Dance With Flair LLC

NAME OF PARTICIPANT:   _______________________________________

MEDICAL INFORMATION

Please describe any information regarding any medical problem, medications, or special needs that you feel would be helpful to the instructor in a classroom situation:

______________________________________________________________________________________

______________________________________________________________________________________

EMERGENCY CONTACT INFORMATION

Emergency Contact Person #1: ______________________                       _______________________ 

                                                                 Name                                                       Phone Number

Emergency Contact Person #2:_______________________                      _______________________

                                                                 Name                                                       Phone Number

WAIVER AND RELEASE OF CLAIMS

             I, the parent or legal guardian of the child Participant in the Dance With Flair LLC dance program hereby recognize and acknowledge that there are certain risks of physical injury from participation in the dance program and I agree to assume the full risk of any injuries, including death, damages or loss, which the Participant may sustain as a result of such participation. I hereby agree to waive and relinquish all claims for injuries, damages, or loss that the Participant or I may have, as a result of the Participant’s participation in the dance program against Dance With Flair LLC, and its members, officers, employees, landlords and all other agents.

             I hereby agree to indemnify, defend, and hold harmless Dance With Flair LLC, its officers, members, employees, landlords and all other agents, from any and all claims made by or on behalf of the Participant or me arising out of, connected with, or in any way associated with the activities of the dance program.

             I verify that I am not aware of any medical or physical condition that would prevent the Participant from participating in dance classes, and further certify that no doctor has recommended that the Participant refrain from participating in a dance program or related activities.

             I hereby give consent to the use of my child’s picture or likeness in any Dance With Flair LLC related promotional or advertising material and on the Dance With Flair website.

             I have carefully read this document and fully understand the registration materials, policies and this Waiver and Release of Claims.

Parent/Legal Guardian:_________________________________                 Date:__________________