2020-2021 Covid-19 Waiver & Release
Apr 23, 2021 12:22 PM
Please note changes we have made to follow the State of Ohio’s guidelines for COVID-19 for our industry.
Masks are required while entering the dance studio until we have taken your dancer’s temperature. He/she can carefully remove the mask once in the dance room at the designated place for his/her belongings. If you prefer for your dancer to leave on the mask, please be sure your dancer knows what to do.
We ask you to read, and checkmark this to acknowledge this waiver. Thank you for your cooperation.
COVID-19 Safety Commitment: Marietta Dance Academy has set precautions to keep our customers and staff safe and can answer questions or review our protocols with our customers.
Note: We will continue offering all classes on Zoom for students who prefer to stay at home.
Client Release Waiver
The CDC describes COVID-19 symptoms as fever, chills, cough, shortness of breath or difficulty in breathing, fatigue, body aches, headache, sore throat, congestions, runny nose, nausea, vomiting, diarrhea, loss of taste and/or smell.
______ I understand these many of COVID-19 symptoms are similar to the common cold or flu. We will be honest and stay at home if experiencing any of these symptoms.
______ I affirm that neither myself (participant) nor anyone in my household or immediate circle currently have these symptoms.
______ I affirm that myself (participant) or anyone in my household or immediate circle have not been diagnosed or exposed to COVID-19 within the past 30 days.
______ I affirm that myself (participant) or anyone in my household or immediate circle have not traveled outside the country or any area considered as a “hot spot” in the past 30 days.
______ I understand that Marietta Dance Academy or staff cannot be held liable for any accidental exposure due to the COVID-19 virus.
Signature: _______________________________ Date of class: _____/_______/________
Waiver and Release Form
PLEASE PRINT, SIGN AND RETURN TO OFFICE
Marietta Dance Academy Waiver and Release Date______/______/_________
Part 1 As a participant of or as the legal guardian of the minor referred to as the participant at the Marietta Dance Academy dance & tumbling program, I attest that the participant is physically & emotionally fit to participate in programs known as and associated with any Marietta Dance Academy activity. I understand that there are certain risks of physical injury as a participant of any individual or group classes, workshops, or other activity organized by the Marietta Dance Academy. I hereby waive and release all claims, liabilities, actions, damages, costs or expenses of any nature whatsoever for injuries the participant might sustain arising out of the program now or at all times in the future.
The registered participant or, in case of a minor, their parent(s) or guardian(s) agrees to indemnify and hold harmless the Marietta Dance Academy and its instructors associated to the program from any and all liabilities, claims, actions, damages, costs or expenses of any nature. By registering as a participant of the Marietta Dance Academy, the participant agrees to abide by Marietta Dance Academy’s policies and regulations for safety at all times. The participant agrees to the terms outlined in this liability waiver and release.
In the event of an emergency, I hereby consent to medical treatment the participant may require for injury or illness and authorize the designated adult instructor to obtain such treatment. I hereby release and discharge the responsible adult and the Marietta Dance Academy from any and all debts, judgment or suits of any kind that may arise or be occasioned by the applicant’s participation in this event.
Signature of Parent or Legal Guardian of Participant ___________________________________
Printed Name ________________________________Cell Phone ______________________
Other person to contact in case of emergency: _____________________________________
Cell Phone __________________ Relationship to student _____________________________
Food allergies, asthma, ADHD, hearing problems, etc. _________________________________
Family Dr.’s Name: _________________________________ Phone______________________
Insurance Company _______________________________ Policy# ______________________
Name of policy holder ________________________ Relationship to student _______________
Part 2 Use of media for the Marietta Dance Academy’s website and/or any advertisement for the Marietta Dance Academy may include pictures, video or testimonials from the classroom, performance or other lawful events of the Marietta Dance Academy.
YES ______ I DO give permission to include the participant’s image in any such type use.
NO ______ I DO NOT give permission to include the participant’s image in any such type use.
Signature of Parent or Legal Guardian of Participant _______________________________________