Medical Release Form
Jan 22, 2020 08:50 AM
In consideration of the services of Madison Avenue Dance Studio, LLC (referred to as MADS) its owners, agents, officers, employees and all other persons or entities acting in any capacity on their behalf, I hereby agree to release, discharge and hold harmless MADS, on behalf of myself, my children, my parents, my heirs, assigns, personal representative and estate as follows:
I understand and acknowledge that the activities that I or my child engage in while on the premises or under the auspices of MADS pose known and unknown risks which could result in injury, paralysis, death, emotional distress, or damage to me, my child, to property, or to third parties. I hereby voluntarily release, forever discharge and agree to hold harmless and indemnify MADS from any and all liability, claims, demands, actions or rights of action, which are related to, arise out of, or are in any way connected with my child’s participation in MADS-related activities. By signing this form I waive and release any person, group, or business affiliated with MADS from any and all liabilities for personal injury of any kind, which arise out of or relate to my child’s participation in any dance class, workshop, studio event, parade, performance, competition, in the dance studio building or any building related to the studio practice, rehearsal, warm ups and performances. I have fully read and agree to all policies of MADS found in the Studio Info Packet and on the website. I give MADS permission to use my child’s photo and/or video for promotional uses.
I agree that I have had adequate time to read this information and fully process it.
I hereby authorize MADS to charge my credit or debit card for all services and products related to my family’s enrollment in classes and activities at MADS including but not limited to tuition, special events, costumes, fees, accessories, etc. If I elect to pay annual tuition via monthly installments, I understand that my credit or debit card will continue to be charged on the monthly, session or periodic basis unless I notify the studio in writing 30 days before intent to discontinue via email to email@example.com.
I have read this entire agreement and understand that I will be held fully responsible for its terms and conditions of service, including a thirty day written notice by email to MADS of any intent to discontinue. I understand that once the monthly installments for my annual tuition have occurred there will be no refund given if I decide to discontinue. I agree to notify MADS immediately of any change in the status of my charge account including but not limited to card expiration, name change, limitation of use, loss or theft or the card, etc. In the event that the amount charged is refused for whatever reason, I accept responsibility for full payment for the amount charged as well as a NSF fee of $10.00