RELEASE AND AUTHORIZATIONS
Name of Student: _________________________________________________ has no health problems or conditions of which the dance center should be aware (such as heart, back, medical, allergy, muscular, pregnancy, diabetes, epilepsy, chemical or neurological condition, particular medication, knee/kidney/shoulder problems, etc.). I understand that risk of injury is inherent in any physical activity, and I knowingly and voluntarily accept that risk on behalf of myself and my child. I, the undersigned, for myself, my heirs, administrators, and executors, hereby waive and release Southern Arc Dance Center LLC, its staff, independent contractors, and employees from any claims or damages of any kind arising out of my child’s participation in the exercise and/or dance program of Southern Arc Dance Center LLC. I certify that the student above is in proper physical condition to participate in the exercise/dance program and that he/she has been examined by a licensed physician and found to be in appropriate physical condition to participate in said program. I, the undersigned, do hereby authorize Southern Arc Dance Center, LLC or its designated agents (teachers, Independent contractors, or administrators employed by Southern Arc Dance Center LLC) to obtain medical treatment for my said child in emergencies where I cannot be reached in time to authorize the treating physician to provide such emergency medical services. I understand that I am responsible for any medical expenses and that the absence of health insurance does not make Southern Arc Dance Center LLC accountable for paying medical expenses. This authority includes the power to authorize any necessary treatment under the circumstances by a licensed physician. By sighing below, I acknowledge that I am aware that classes, studio showings, and performances may be photographed and videotaped; I am releasing the registered student’s image so it may be used for promotion, advertising, and archival use. This power is, in essence, a power of attorney and shall remain in effect until revoked by me in writing.
EMERGENCY INFORMATION
Medical Information__________________________________________________________________________
Physician: ___________________________________________________________________________________
Hospital Preference: ___________________________________________________________________________
Insurance Company Policy No.: __________________________________________________________________
Allergies (food, medicine, etc.): ___________________________________________________________________
Additional Information/Comments (i.e., blood transfusions, etc.):_________________________________________
I grant permission to Southern Arc Dance, LLC, and its agents or employees, to use photographs of me or the minor named here for studio publications, including brochures, newspapers, and the Southern Arc Dance Center, LLC social media and Website at www.southernarcdance.org.
I grant Southern Arc Dance the unrestricted right to use and publish photograph or video footage taken of me/and my minor child while participating in dance class, performing, or in the company of Southern Arc Dance Center, LLC, I waive any right to royalties or other compensation arising from the use of my photograph, and if singing on behalf of a minor named herein, I waive all such rights of the child named herein.
I agree on my behalf or the minor child named herein to release and hold harmless Southern Arc Dance Center, LLC, and its agents, Independent contractors, or employees from any claims arising from the related use of the photographs. I acknowledge that by signing this form, I give Southern Arc Dance full copyright and authority to publish photography and agree to the above-mentioned terms.
For the Student:
As a Student of Southern Arc Dance Center, LLC, I understand that I am held to a high standard of conduct. I will respect my instructors and classmates. I will be on time to class and dress and conduct myself appropriately in the center/class.