Dancer's Birthday:*

Dancer's T-shirt Size:*

Dancer's Pant Size:*

Which of the following does the dancer prefer as praise during class? *

Is the dancer allowed to have stickers, snacks, or prizes at the end of class?*

If the dancer wants to leave the classroom to take a break: *

If the dancer wants to go to the bathroom during class:*

If the dancer wants to leave the classroom to speak with a parent:

As the legal guardian of (dancer’s name here), I authorize all A Chance to Dance staff to include directors, instructors, substitute teachers, assistants, and assigned buddies and volunteers to instruct, teach, and assist my dancer.*

I agree and pledge to follow the rules and regulations of A Chance to Dance and Barbie Rhodes Dance Studio. *

I also agree to having my dancer’s photo and/or likeness used indefinitely by the organization for advertising and marketing endeavors and waive all rights to such images.

I understand that my financial account with A Chance to Dance must be kept in good standing. I understand that tuition is due on the first Friday of every month and a $5 late fee will be applied for each week that I am late on tuition, not to exceed $50. *

In full understanding and with all regards to A Chance to Dance and/or Barbie Rhodes Dance Studio facilities or operating locale(s), the undersigned, now and forever, hereby releases and agrees to indemnify, and hold harmless these organizations...*

inclusive of but not limited to their boards, owners, stockholders, agents, employees, volunteers, successors, and assigns from any and all liability, claims, or causes of action resulting from any loss, insult, or injury of any kind by the undersigned...*

or any of the undersigned’s agents, dependents, patients, guests, clients, or visitors present as a result of the undersigned. This release, indemnification and hold harmless includes, but is not limited to, claims for personal injury and/or property loss*

including all damages, costs, and attorney fees incurred as a result thereof, whether resulting from building defects, negligence, gross negligence, intentional acts, or omissions of A Chance to Dance (class or organization), Barbie Rhodes Dance Studio,*

their employees, assistants, volunteers, the undersigned, or otherwise. I understand that our volunteer staff may or may not receive any specific, legal, medical, official, or formal training and/or education through A Chance to Dance.*

The dancer’s legal guardian will be present and have overall responsibility of their dependent’s safety, health, and welfare during the entire period of dance instruction, for each class, rehearsal, and performance.

In addition, I understand that if my dancer has health concerns including seizures , fainting, or other serious conditions, I may not, under any circumstances, leave the premises in case of a medical emergency.*

I understand that while dancing with ACTD and Barbie Rhodes Dance Studio in class, rehearsal, and performances, my dancer(s) may be at risk of physical illness or injury (minimal, serious, catastrophic, and/or death), and I acknowledge that I assume risk.*

I am aware that this medical waiver releases ACTD and Barbie Rhodes Dance Studio from all liability, without limitation, from any illness or injury that may occur and acknowledges my voluntary and knowing assumption of the risk of illness/injury.*

I acknowledge that the volunteers associated with A Chance to Dance that are directly involved in the instruction of my dancer will receive the health information found on the health questionnaire provided by the legal guardian.*