Northern California Dance Conservatory, Inc. (NCDC) Release & Information Form

Dancers Name: ______Age_____ Dance Cell Ph ______

Last First

Mothers Name:______Fathers Name:______

Home Phone:______Mom’s Cell:______ads Cell:______

Home Address:______City:______State:______Zip:______

Parent Email:______Dancer Email: ______

If my child is ill or has an emergency & I cannot be reached, please call & release my child to:

Name Relationship Cell Number

Please list any known health problems or allergies your child may have : ______

Doctor:______Phone Number:______

Medical Insurance:______Group Number :______

Communication:

The primary source of communication from NCDC to our families is done through email. Please check your email regularly and updated you account should your email address change.

Liability Release:

I am aware that dance training & the athletic exercise associated with it can place unusual stress on the body & may carry the risk of physical injury. On behalf of myself or my dependent, I assume the risk & agree that NCDC shall be held harmless & is not liable in any way for any injury or accident sustained to myself or my child during attendance in any classes, rehearsals, performances or any related functions or events. I understand that good training involves physical manipulation and adjustment of the student’s body by professional artistic staff. I also understand that my child may be chaperoned or supervised by volunteers.

Medical Release:

I hereby give my permission to the management, faculty, and staff of NCDC, Inc. to authorize any emergency medical care that may be required during my child’s participation in classes, performances, or any related NCDC events. I understand that I am responsible for any and all charges as a result of such care or medical treatment.

Photo and Publicity Release:

I hereby authorize NCDC to record my child’s picture & voice on photographs, films, or tapes, to edit these recordings at its discretion & to incorporate these recordings into movie & sound films on tapes, radio or television programs, and for publicity, and fund raising purposes. I agree for photos to be posted on the NCDC website. I acknowledge that no such promise of compensation was made by NCDC, Inc. I give NCDC, Inc. the absolute right and permission to use my child’s photographs in its promotional materials & publicity efforts. I release NCDC, Inc. their officers, employees, agents and designees, from liability for any violation of any personal or proprietary right I may have in connection with such use.

Tuition/ Credit Card Authorization:

NCDC Season is like a school year; we run from September through June with camps and intensives in July. The studio is generally closed during August. Monthly fees are automatically deducted from your check card or credit card on the first of each month. No checks are accepted. Tuition is charged monthly regardless of the number of weeks in the month. We do not charge more for the months with 5 weeks nor do we prorate for vacations or holidays. You must drop a class by the 15th of the month to stop the automatic payment on the 1st of the following month. Classes must be dropped in writing either by email () or fax (916-791-4518). There are no refunds of tuition for classes you’re scheduled to attend whether you attend the class and there are no refunds for registration or any fees related to any shows or productions.

I am the legal custodial parent or legal guardian of this child & have read the Release & Information form.

Signature______Date______

Parent/Guardian

NCDC 920 Reserve Dr. Suite 110 Roseville, CA 95678 (916) 791 - 2061