~Capital Cougarettes Dance Team ~ Workshop Release Form

Participant Name___________________________________________________________________________

Participant Address __________________________________________________________________________

Parent Name (s) _____________________________________________________________________________

Child’s Doctor & Phone Number ________________________________________________________________

Participant Grade________________________________ Participant PhoneNumber______________________

Parent Cell Number ______________________________ Parent Cell Number __________________________

Child’s Insurance Company & Policy Number_____________________________________________________

List any Medical or Physical Limitations that we should be aware of._________________________________________________________________________________________

___________________________________________________________________________________________

This Dance Clinic is NOT sponsored by the Olympia School District.

I acknowledge that the minor and I fully understand that the minor’s participation may involve risk of serious injury or death, including economic losses, which may result not only from the minor’s own actions, inactions, or negligence, but also from the actions, inactions, or negligence of others, the condition of the facilities, equipment, or areas where the event or activity is being conducted, the rules of play, or this type of event or activity;

I assume any and all risks of personal injuries to the minor and authorize the Sponsor to contact or employ a licensed physician to render any medical treatment that may be deemed necessary for the minor or to take and admit the minor to any hospital. If such medical treatment or hospitalization is required, I agree to pay all medical and hospital bills relating thereto, permanent or partial disability or death and damages to the minor’s or my property, caused by or arising from the minor’s participation in the event or activity;

I release, waive, discharge and relinquish the Olympia School District, Capital High School or the Capital Dance Team and their respective officers, volunteers, dancers, coaches and agents from any liability, loss, damage, claim, demand or cause of action against them attributable to the minor’s participation in the event or activity, whether same shall arise by their negligence or otherwise.

Parent Signature: _________________________________________________________________________________________

Date:_____________________________________

For more information email coach Jaci Gruhn at jgruhn@osd.wednet.edu or SungJa Albright at salbright@osd.wednet.ed