DC Dance Club Health and Fitness, Liability Waiver, Informed Consent Form

I.  Self – please print

I, _____________________________________, have enrolled in a program* offered through DC Dance Club**.

II.  Child – please print

I, _____________________________________, have enrolled my child in a program* offered through DC Dance Club **.

Child 1, ____________________________________________________________  please print

Child 2, ____________________________________________________________  please print

Child 3, ____________________________________________________________  please print

Emergency contact for legal dependents:

Name   ____________________________________________________________  please print

Phone  ____________________________________________________________  

*  Programs may include, but are not be limited to, private or group classes, workshops, social functions, fundraisers, showcases, competitions.  

** Further, such programs may be offered directly through DC Dance Club or through a third party individual or group using the DC Dance Club venue.

I acknowledge that the services provided may involve strenuous physical activity including, but not limited to, muscle strength and endurance, cardiovascular exertion, and other various fitness activities. I acknowledge that by its very nature dancing involves close physical connection including direct body to body contact. I hereby affirm that I and/or my child/children am in good physical condition and do not suffer from any known disability or condition of a physical or mental nature which would prevent or limit my or their participation in this program.  I acknowledge that it is my responsibility to obtain a medical examination and clearance for myself and/or my child/children prior to engaging in any sport or fitness activity. I hereby assume full and sole responsibility for my own health, safety and well-being and that of my legal dependents.

 I acknowledge that my enrollment and subsequent participation is purely voluntary and is in no way mandated by DC Dance Club. In consideration of my participation in this program, I hereby release DC Dance Club and The Crossroads Market Ltd., their owners, directors, officers, agents, activity providers, employees and successors from any and all action, debts, accounts, claims and demands whatsoever by myself, my heirs, executors, or assigns for any injury of person, including death, or for any damage or loss of property which may be sustained as a consequence of participation in activities or presence on the property of DC Dance Club of me or my child/children.  Injuries may include, but are not limited to, heart attacks, strokes, muscle strains, muscle pulls, muscle tears, broken bones, shin splints, injuries to knees or shoulders or any other joints of the body, injuries to back, injuries to a foot, or any other illness or soreness, physical or mental/emotional discomfort that may be incurred.

This Agreement constitutes the entire agreement between the parties and there are no further provisions, either oral or written.  This Agreement is governed by the laws of the Province of Alberta.  Any notices, requests, demands or other communications will be deemed to be completed when emailed to DC Dance Club Inc. at dance@dcdanceclub.com  Email signatures are binding are considered to be original signatures. Any notices, requests, demands or other communications will be deemed to be completed when emailed to dance@dcdanceclub.com



Signature of Participant or Legal Guardian

_____________________________________      __________________________________________

Print Witness Name    Signature of Witness



Student Information (Please Print)

Name  ____________________________________________________________________________

Address  __________________________________________________________________________

Phone     _____________________________

Email      __________________________________________________________________________

If under 16 years of age, date of birth (day/month/year)  _____________________________________

Might you or your dependent require any medical attention during a class?   Yes   No

If Yes, please provide details



Please initial:

_____  I have read and signed the Health and Fitness, Liability Waiver, Informed Consent form

_____  I have read the DC Dance Club Policies and 

_____ I understand my billing obligations, that all services must be pre-paid and are nontransferable              between classes and/or between students

_____  I understand missed class/cancellations require 24 hour notice to avoid being charged

_____  I give media use rights permission]