DANCER’S NAME                                                                                                                                           

Date:                                                                          DOB:                                                                               

Gender: Male/ Female    Guardian’s Name (if under 18)                                                                                  

Address:                                                   City:                                     Zip:                                                      

Email Address:                                                                                                                                                   

Phone Number:                                                   Cell:                                                                                       

 

I understand that the participation in New Energy’s dance classes and instruction may subject me to certain

physical and medical risks that I agree to assume.  I declare myself to be physically sound and suffering no

physical impairments, conditions or illness that would prevent my participation in a dance program at New

Energy. I further understand that New Energy assumes no responsibility for my personal safety and I hereby

 release New Energy, its Artistic Director, teachers, choreographers and staff from any and all liability which may arise directly or indirectly from any damage to me or my property as a result of my participation in dance, exercise and/ or use of the facility at New Energy.

 

My signature indicates full understanding and compliance with the above waiver of liability as well as New

Energy’s general policies.

 

Print Name (guardian):                                                                                                                         

Signature:                                                                                                                                              

 

Dance Studio