Samba in the Streets 2019
Participation, Release, Photography and Waiver of Liability Form .
Every event organized by Viver Brasil Dance Company requires a document completed by a program participant or guardian prior to participation. If necessary, the organization, can provide a copy of this form via email.
Email address *
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Full Name *
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Emergency Contact Information

In the event of an emergency, it might be necessary to contact a parent or guardian. Please provide their information below.
Emergency Contact Full Name *
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Relationship *
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Contact: Phone, Address & Email *
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Email address *
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Release, Photography and Waiver of Liability Agreement
I understand that all the information on this form is voluntarily supplied and may be used and disclosed for the organization, Viver Brasil Dance Company purposes only. I also agree to release and hold harmless the staff, the volunteers, artist and the board of directors of Viver Brasil Dance Company from any and all liability for disclosing this information to agencies and their agents who request assistance for injury incurred while participating within a program offered by the organization. I hereby agree to the terms of this waiver of liability and understand that I am responsible for any cost related to a potential injury. By participating in programming offered by Viver Brasil Dance Company, I understand that I will have the opportunity to learn dance, music and culture of the African Diaspora and its relation to Brazil.

By signing this application, I (parent or guardian, if participant is under 18) grant permission for participation in events without requiring additional permission forms. I also grant Viver Brasil Dance Company permission to use photographs taken at activities I participate in for publication to promote programming and for grant applications.

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