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Jaydie Leigh Dance Kimberling City Waiver Disclaimer

Student Name:  {name}               Phone:  {phone}               D.O.B.:  {dob}

Address:  {address}

Emergency Contact:  {contact_name}                Emergency Contact Phone:  {contact_phone}

Emergency Contact Relationship:  {contact_relation}

Read Carefully Before Signing – Acknowledgement, Waiver & Release from Liability

I understand that there are risks of physical injury associated with, arising out of and inherent to the activity of dance. In recognition of this acknowledged risk of injury, I knowingly and voluntarily waive all right and/ or causes of action of any kind, including any and all claims of negligence arising as a result of such activity from which liability could accrue to Jaydie Leigh Dance, its officers, agents, employees, instructors, subsidiaries, parent corporations, and all affiliated entities (hereinafter collectively referred to as “Jaydie Leigh Dance”). I hereby agree to release Jaydie Leigh Dance and hold Jaydie Leigh Dance harmless of all liability, and hereby acknowledge that I knowingly and voluntarily assume full responsibility for all risks of physical injury arising out of active participation in dance on behalf of the participant. I have signed this document voluntarily and of my own free will in exchange for the privilege of participation. I also give Jaydie Leigh Dance permission to use my child’s picture in or on any form of advertisement for Jaydie Leigh Dance or a Jaydie Leigh Dance affiliated event. If I am a minor, my parent and/or legal guardian has also signed this document releasing Jaydie Leigh Dance from any and all such liability described above and has acknowleged that I am knowingly and voluntarily assuming all risks of injury inherent to this activity. The participation has my permission to participate in Jaydie Leigh Dance events. I warrant the below information is complete and correct. I further release Jaydie Leigh Dance of all liabilities associated with my child’s attendance at Jaydie Leigh Dance.

Name of member or guardian signing the document:   

Date:  {sign_date}