The information requested is confidential and for emergency use only. In the event of a medical emergency, this information will be used by authorized emergency personnel. Please be honest when completing all pertinent information.
In the case of emergency, I give permission for my information to be released to emergency personnel. I also agree that any of my emergency contacts listed on this card may be notified in an emergency, as needed.
As parent/guardian of the above dancer, I certify that he/she is in excellent health and has no physical, mental, or emotional problems, which are likely to prevent participation in strenuous physical activities. I agree to hold harmless Studio 55 Dance and its staff and agents and herby release them from any liability on account of injuries sustained by student while participating in any activities while participating in programming at Studio 55 Dance. I give permission for student to be medically treated for illness occurring or injury sustained during such participation and certify the he/she is covered by medical insurance which will reimburse Studio 55 Dance and it's agents for expenses incurred to them.
I give consent for dancer to be photographed, videotaped, or filmed while participating in Studio 55 Dance activities and for the resulting media to be used for educational and promotional purposes. I have read and understand the above as parent/guardian of the above dancer.
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. However, there remain many unknowns about COVID-19, how it spreads, and its impact on children.
By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending Studio 55 Dance programming and that such exposure or infection may result in severe illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at Studio 55 Dance programming may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Studio 55 Dance employees, contractors, volunteers, and program participants and their families. I voluntarily agree to assume all of the foregoing risks associated with COVID-19 and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with COVID-19 because of my child(ren)’s attendance at Studio 55 Dance or participation in Studio 55 Dance programming (“Claimsâ€). On my behalf, and on behalf of my child(ren), I hereby release, covenant not to sue, discharge, and hold harmless Studio 55 Dance, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto.
I agree to all of the terms listed within the 2024-2025 Studio Handbook General Policies of Studio 55 Dance and will take full responsibility for all monetary fees as well throughout the 2024-2025 season.
