Dance Permission Form

Dance Permission Form

Student Information

Student Name:

Date of Birth:    Student ID:

Student is 18 years of age or older and will sign as an adult:

Parent / Guardian (if applicable)

Event / Class Details

Instructor:    Location:

Event / Class Date:    Start Time:    End Time:

Transportation provided by school or program:    Student will be transported by parent/guardian:

Emergency Contact & Medical Information

Emergency Contact Phone:    Relationship:

Primary Physician:    Phone:

Consent, Authorization, and Release

I, the undersigned as parent or legal guardian of the student named above, or as an adult student if indicated, grant permission for the student to participate in the dance activity described herein. I acknowledge that participation in dance activities involves physical exertion and inherent risks including, but not limited to, sprains, strains, falls, and other injuries. I assume all risks associated with participation to the fullest extent permitted by law.

I authorize program staff, volunteers, or medical personnel to obtain and provide emergency medical treatment should the student require it and I cannot be reached promptly. I agree to be financially responsible for such treatment. I release and hold harmless the school, program, its board members, employees, instructors, volunteers, and agents from any claims arising out of participation except in cases of gross negligence or intentional misconduct.

I consent to the administration of over-the-counter medications and application of first aid by authorized staff according to program policies in the event of minor injury or illness:    I authorize staff to administer prescribed medication as described in writing below:

Photo/Video Release: I grant permission for photographs, video, or other media of the student to be used by the school or program for educational, promotional, or archival purposes without compensation. I may decline by checking: (check to decline)

Fees & Payment

Participation Fee (if applicable): $    Payment Method: Cash    Check    Card

Behavioral Expectations

I acknowledge that the student must adhere to the program's code of conduct and safety rules. Failure to comply may result in disciplinary action, including removal from activities and forfeiture of fees at the program's discretion. I accept responsibility for costs or damages caused by willful misconduct of the student.

By signing below I certify that I have read and understand this document, that the information provided is accurate to the best of my knowledge, and that I am authorized to grant the permissions set forth herein for the student named above.

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