Medical and Liability Release
I am the parent/guardian and I warrant that to the best of my knowledge and belief, he/she is physically and mentally able to participate in Adirondack Dance Academy and/or Adirondack Dance Company. With my approval, a license physician has certified based on an independent medical examination that there is no medical evidence, which would preclude his/her participation. I understand that if he/she has Down Syndrome, a full radiological examination to establish the absence of Atlanto-azial Instability is needed.
If a medical emergency should arise during his/her participation at dance at a time when I am not personally present so as to be consulted regarding his/her care, I hereby authorize Adirondack Dance Academy and/or Adirondack Dance Company, on my behalf, to take whatever measures are necessary to ensure that he/she is provided with any emergency medical treatment including hospitalization, which Adirondack Dance Academy and/or Adirondack Dance Company deems advisable in order to protect his/her health and well-being.
I have read and fully understand the provisions of the above financial and medical release. Through my signature on this release form, I am agreeing to the above provisions on my own behalf and that of my child. I also realize the potential risk involved with my child’s participation in this program. I therefore will not hold the Adirondack Dance Academy, Adirondack Dance Company, its teachers, volunteers or their agents responsible for harm that comes to my child while he/she is participating in this program. Thereby give my permission for him/her to participate at Adirondack Dance Company’s rehearsals and performances.
“X†Signed:_______________________________________ Date:_______________
If not signed by parent, please indicate relationship to student (e.g., grandparent, aunt, uncle, etc.)
NO PART OF THIS DOCUMENT MAY BE OMITED. FAILURE TO SIGN THIS WILL RESULT IN NO CLASSES AT OUR STUDIO.
