Dazzle Dance Center Summer Registration

Dazzle Dance Center Summer Registration

Please fill this form out completely and bring with you to register.

Name: ______Nickname: ______

Birth Date: ______Age as of 8/1: ______Grade: ______

Address: ______

City, State, Zip: ______

Phone Numbers: ______

E-Mail Address: ______

Parents’ Name: ______

Optional Contact & Phone Number: ______

Optional Contact's Relationship to Child: ______

Summer Camp Attending:

_____ Hip Hop – June 22-24 - $50_____ Mini Camp – June 29 – July 1 - $50

_____ Level 1 – July 15-17 - $50_____ Level 2 – July 20-22 - $50

_____ Level 3 – July 27-30 - $60_____ Level 4 – August 3-7 - $75

For Office Use

Paid Camp Fee: ______Date: ______

Dazzle Dance Center, LLC

Liability Release Form

I understand that there are risks of physical injury associated with, arising out of and inherent to the activity of dance. In recognition of this acknowledged risk of injury, I knowingly and voluntarily waive all right and/ or causes of action of any kind, including any and all claims of negligence arising as a result of such activity from which liability could accrue to Dazzle Dance Center, LLC, it’ employees, instructors, and all affiliated entities (hereinafter collectively referred to as “Dazzle Dance Center, LLC”.

I hereby agree to release Dazzle Dance Center, LLC and hold Dazzle Dance Center, LLC harmless of all liability, and hereby acknowledge that I knowingly and voluntarily assume full responsibility for all risks of physical injury arising out of active participation in dance on behalf of the participant.

I am aware that this is a release of liability and an acknowledgement of my voluntary and knowing assumption of the risk of injury. I have signed this document voluntarily and of my own free will in exchange for the privilege of participation.

I also give Dazzle Dance Center, LLC permission to use my child’s picture in or on any form of advertisement for Dazzle Dance Center, LLC or a Dazzle Dance Center, LLC affiliated event.

I also agree to give written notification of withdrawing from classes. Only after my notification to Dazzle Dance Center, LLC will I no longer be liable for future charges.

If I am a minor, my parent and / or legal guardian has also signed this document releasing Dazzle Dance Center, LLC from any and all such liability described above and has acknowledged that I am knowingly and voluntarily assuming all risks of injury inherent to this activity.

The participant has my permission to participate in Dazzle Dance Center, LLC Events. I warrant the below information is complete and correct. I further release Dazzle Dance Center, LLC of all liabilities associated with my child’s attendance at Dazzle Dance Center, LLC.

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Parent/ Guardian Signature Date

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Participant’s Name Date

Please list any medications the participant is taking, and any other special medical instructions.

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