STUDENT NAME *

First Name

Last Name

PARENT/GUARDIAN NAME *

First Name

Last Name

MAILING ADDRESS *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

*

I have chosen to have my child or myself (if over 18 years of age) to participate in dance instruction given by “Empire Performing Arts”. I acknowledge that I understand the nature of the activities my child will be participating in and that my child is in the proper physical condition and capable of participating in the related activities, understanding that Empire Performing Arts is not in any way responsible for making such a determination. In consideration of my child’s participation in any dance instruction program, I understand and agree on behalf of myself and my child, to release, hold harmless, and discharge Empire Performing Arts from all claims, costs, liabilities, expenses or judgments, including legal fees and court costs for any occurrences in connection with any dance instruction. I assume all risks to my child in connection with any instruction and further release Empire Performing Arts and its owners and employees from liability for any injury sustained by my child while he or she is enrolled in any dance instruction program, including all risks reasonably connected with such activity whether foreseen or unforeseen. I understand that Empire Performing Arts is not responsible for my child or other children under my supervision who are left unsupervised in the common areas and areas surrounding the dance studio and that Empire Performing Arts will only be supervising my child when he or she is participating in scheduled dance activities, programs or instruction. I understand that Empire Performing Arts is not responsible for personal property that is lost, damaged or stolen while I or my child is at or on the premises where Empire Performing Arts operates. I acknowledge and agree that it is my responsibility to maintain my own accident and health insurance coverage that provides adequate coverage for myself and my child while attending classes operated by Empire Performing Arts. I authorise and agree that Empire Performing Arts may take and use photographs or videos of myself and/or my child as needed for advertising and/or public relations projects and give consent to this. My electronic signature is proof of my intention to execute this complete and unconditional waiver and release of all liability pursuant to the terms herein, and agreement as to all terms and conditions contained above.