Release & Authorization
Sep 07, 2024 06:29 PM
RELEASE AND AUTHORIZATION
Name of dancer(s): _________________________________________________
: _________________________________________________
: _________________________________________________
Indicated in the space below are any health problems or conditions of which the studio should be aware (such as heart, back, medical, allergy, muscular, pregnancy, diabetes, epilepsy, chemical or neurological condition, special medication, knee/kidney/shoulder problems, etc.). I understand that risk of injury is inherent in any physical activity and I, on behalf of myself and my child, knowingly and voluntarily accept that risk. I, the undersigned, for myself, my heirs, administrators, and executors, hereby waive and release Gregory Marchetti individually and Asylum Dance Project, LCC and its staff from any and all claims or damages of any kind arising out of my child’s participation in the exercise and/or dance program of Asylum Dance Project,LLC I further certify that the aforementioned student 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 proper physical condition to participate in said program. I, the undersigned, do hereby authorize Gregory Marchetti with their designated agents (being teachers or administrators employed by Asylum Dance Project,LLC.) to obtain medical treatment for my said child in emergency situations 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 Asylum Dance Project,LLC. responsible for payment of medical expenses. This authority includes the power to authorize any and all treatment deemed necessary under the circumstances by a licensed physician. This power is in essence a power of attorney and shall remain in effect until written notice from a guardian or student 18 years of age or older.
SIGNATURE OF STUDENT (OVER 18)_________________________DATE:____________
SIGNATURE OF PARENT/GUARDIAN: _________________________DATE: ____________
WITNESS
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