CT High School DanceFestival

Saturday May 14, 2016

Central CT StateUniversity

New Britain, CT06050

School/Group Registration Form(A)

PleasefilloutSchool/Group Registration Form(A)andreturntotheaddressbelowbyMarch 25, 2016alongwithpayment and StudentRegistrationForms(B). Pleasecollectallformsandfeesandmailtogetherinoneenvelopetotheaddress. The package should include Form (A) with payment and all Student Registration Forms(B).

Name ofSchool:

Name of Contact Teacher:______Teacher’s PhoneNumber(s):

Teacher’sEmail:______

School Street Address:______

Early Bird Feeby11/24/2013 / Registration Feedue by 3/25/16 / Amount
Registration FeeperSchool/Studio / $50 / $100
Participation FeeperStudent / $50xstudents / $75x_ students / $
OptionalAdjudication Feeperentry (up totwoentries) / $100xentries / $100 x ____entries / $
IndividualParticipant(noschool/studio) / $75 / $100
Total
$

CT High School DanceFestival Saturday May 14, 2016Central CT StateUniversity

New Britain, CT06050

Student Registration Form(B)

Each participant needs to complete a Student Registration Form (B) with parental consent and signature. Please return to contactteacher.

Participant:

LastName:FirstName:

Date ofBirth:Gender (circle): M F Email:

HomeAddress:

City:State:ZipCode:

High School/Studio andAddress:

Contact TeacherName:

ACCEPTANCE OF RISK ANDRELEASE:

Check the applicablebox:

I,theaboveparticipant(Participant)ameighteenyearsofageoraboveandacknowledgethatIintendtoparticipateinthe2016CTHighSchoolDanceFestival(Activity)atCentralConnecticutStateUniversity,1615StanleyStreet,NewBritain,Connecticut06050(CCSU)onSaturday, May 14, 2016.

Iamtheparent/legalguardianoftheabove-namedparticipant(Participant)whoisundereighteenyearsofage,andIamfullycompetenttosignthisrelease.IgivepermissionforParticipanttoparticipateinthe2016CTHighSchoolDanceFestival(Activity)atCentralConnecticutStateUniversity,1615StanleyStreet, NewBritain,Connecticut06050(CCSU)onSaturday,May 14, 2016.

I,theaboveparticipantorparent/legalguardianoftheabove-namedparticipantwhoisundereighteenyearsofage,recognizethattherearerisksandhazardsdirectlyorinherently involved in the Activity and that Participant may become injured during participation. With full knowledge of the facts and circumstances surroundingthisActivity, I, the above participant or parent/legal guardian of the above-named participant who is under eighteen years of age, voluntarily undertakethisActivity/voluntarily give permission for the Participant to undertake this Activity and KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, BOTHKNOWNANDUNKNOWN,EVENIFARISINGFROMTHENEGLIGENCEOFCENTRALCONNECTICUTSTATEUNIVERSITY,FROMTHEPARTICIPANT’SPARTICIPATION IN THISACTIVITY.

I,theaboveparticipantorparent/legalguardianoftheabove-namedparticipantwhoisundereighteenyearsofage,assureofficialsofCCSUthatParticipanthasadequatehealthinsurancenecessarytoprovideforandpayforanymedicalcoststhatmaydirectlyorindirectlyresultfromtheParticipant’sparticipationinthisActivity.I,theaboveparticipantorparent/legalguardianoftheabove-namedparticipantwhoisundereighteenyearsofage,assureCCSUthattherearenohealth-relatedreasonsorproblemsthatprecludeorrestricttheParticipant’sparticipationinthisActivity.

IN CONSIDERATION OF CCSU PERMITTING PARTICIPANT TO PARTICIPATE IN THE ACTIVITY, I HEREBY ASSUME ALL THERISKSASSOCIATED WITH SUCH PARTICIPATION AND I AGREE TO HOLD THE STATE OF CONNECTICUT, THE CONNECTICUT STATEUNIVERSITYSYSTEM,ITSBOARDOFREGENTS,ANDCCSU,THEIREMPLOYEES,AGENTSREPRESENTATIVESANDVOLUNTEERSHARMLESSFROMANYANDALLLIABILITY,ACTIONS,CAUSESOFACTION,CLAIMSORDEMANDSOFANYKINDANDNATUREWHATSOEVER,INCLUDINGTHOSEARISING FROM THE NEGLIGENCE OF CCSU, WHICH MAY ARISE BY OR IN CONNECTION WITH MY PARTICIPATION IN THE ACTIVITY.THETERMSHEREINSHALLSERVEASARELEASEANDASSUMPTIONOFRISKFORMYHEIRS,ESTATE,EXECUTOR,ADMINISTRATOR,ASSIGNEES,AND FOR ALL MEMBERS OF MYFAMILY.

I,theaboveparticipantorparent/legalguardianoftheabove-namedparticipantwhoisundereighteenyearsofage,havereadtheforegoingandfullyunderstanditscontents.Iunderstandthatbysigningthisassumptionofriskandreleaseofliabilityagreement,IwillbegivingupsubstantialrightsandIsignthisdocumentfreelyand voluntarily without anyinducement.

ThisdocumentshallbeconstruedinaccordancewiththelawsofConnecticut,withoutregardtoitsprinciplesofconflictsoflaws.

MediaRelease:

I,theaboveparticipantorparent/legalguardianoftheabove-namedparticipantwhoisundereighteenyearsofage,herebygivemyconsenttoallphotographsandvideorecordingstakenoftheParticipantbyCCSUandotherparticipatingpartiesduringtheActivityandunderstandthatanysuchmaterialbecomesthepropertyofCCSUandmaybecopiedorotherwisereproducedbyCCSUandusedbyCCSUforeducational,instructional,orpromotionalpurposes.

Participant Signature (if 18 orover)Date

Name of Parent/Guardian (if Participant is under18)

Signature ofParent/GuardianDate