Today's Date

Student's Name

Date of Birth

Address

Town/City

Postal Code

Email Address

Home Phone

Mother's Name

Mother's Cell Phone

Mother's Work Phone

Father's Name

Father's Cell Phone

Father's Work Phone

Emergency Contact (Not Parent/Guardian)

Allergies

How did you hear about us?

Referral Name

Have you had any dance training? If so, what subjects and for how many years?

Subjects Requested

Participation Liability Waiver & Hold Harmless Agreement

As a participant or participant's parent/legal guardian, I understand that by participating in any dance class, workshop, rehearsal or performance on or off the premises of Darcy's School of Dance Inc. involves inherent risks. I freely accept and assume all risks and hereby fully release and discharge Darcy's School of Dance Inc., its owners, employees, instructors, assistants, choreographers and volunteers from any and all claims from injuries, damages or loss which I or my minor child may have or my occur as a result of participation in Darcy's School of Dance activities. I authorize Darcy's School of Dance to use any photography/video obtained in class or any studio event for promotional/marketing purposes.

I agree to the above waiver.

Class placement will be approved by the studio.

Submit

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