Student Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Birthday *

MM

DD

YYYY

Mother's Name

First Name

Last Name

Mother's Mobile

(###)

###

####

Father's Name

First Name

Last Name

Father's Mobile

(###)

###

####

EMERGENCY CONTACT *

If parent or guardian is not available.

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

Does student have any physical limitations? *

Yes

No

Is the student on any medications?

If yes please speak to the instructor prior to first class.

Yes

No

Previous dance training?

Yes

No

I understand that there is a risk of personal injury with dance classes and performances. I represent that the above named student is in good health and physically capable of participating in dance classes, recitals, and performances. On behalf of myself (and the above named student if different than the undersigned), I hereby waive and release any claim against RMT Dance, its owner, the staff, employees, landlord, and contractors arising out of personal injury occurring in connection with classes, performances or recitals. I accept responsibility for obtaining the appropriate accident, health, and hospitalization insurance to cover the student in the event of personal injury. In the event of an injury or other medical emergency, if I cannot be reached, I authorize you to seek any medical assistance reasonably required in your judgment and agree to be responsible for the medical expenses incurred on behalf of the student. I acknowledge and I consent to the taking of photographs and video during classes and other RMT Dance activities, and further content to the use of these photos or videos in advertisements, as well as positing on social media in connection with RMT Dance. *

By Typing My Name Below, I am Digital Signing that I Agree to the Above Waiver of Injuries / Waiver of Liabilities / Authorization / Consent Signature of parent, guardian, or adult dancer.

First Name

Last Name

I acknowledge that I read, understand, and willingly signed the above waiver, authorization, and consent. *

YES

Date Signed *

MM

DD

YYYY