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
* 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 firstname.lastname@example.org 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 email@example.com
I HEREBY AFFIRM THAT I HAVE CAREFULLY READ THE ABOVE STATEMENTS BEFORE SIGNING AND I AGREE FREELY TO COMPLY WITH THE TERMS OF THIS AGREEMENT.
Signature of Participant or Legal Guardian
Print Witness Name Signature of Witness
Student Information (Please Print)
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
_____ 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]