MIND & MOVEMENT DANCE ACADEMY NY
SUMMER COMPETITIVE DANCE WORKSHOP APPLICATION FORM

DATES: AUGUST 17 - AUGUST 21 2020
TIME: 9:30 AM - 11:30 AM

All Payments are to be paid in full by July 15, 2020 via CashApp $MMDA19.

ZOOM information will be provided after receipt of payment.
@mmdanceacadmyny
STUDENT NAME
STUDENT ADDRESS
STUDENT AGE
STUDENT'S SCHOOL
GENDER
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REGISTRATION TYPE
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DANCE EXPERIENCE
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PARENT/GUARDIAN
PARENT/GUARDIAN PHONE NUMBER
PARENT/GUARDIAN EMAIL ADDRESS
RELEASE OF LIABILITY: I, (name printed above), as parent/guardian or participant, herby acknowledge, agree, promise, and covenant with and release, discharge and hold harmless Mind & Movement Dance Academy, its officers, employees, agents, independent contractors, and volunteers on behalf of myself, my child, any minor in my legal custody, or any minor who I have enrolled in a program with MMDA, my heirs, assigns, personal representative and estate from any known or unknown, anticipated or unanticipated risks which would result in injury, death, physical or mental illness or disease, or damage to myself, to my property, to spectators, or other third parties. I assume all risks of participating and/or volunteering in this event. I certify that I (or my child) have been examined by qualified physician and are physically fit to participate in this year’s activities. I consent (on behalf of my child for him/her) to receive medical treatment and/or diagnostic procedures, which may be advisable in the event of injury, accident and/or illness during or as a result of this event. I understand that the MMDA reserves the right to remove any participant for disciplinary reason. I understand that this event or related activities may be photographed or videotaped. I agree to allow my/my child’s photo, video, or film likeness to be used for any legitimate purposes by MMDA. In the event that a child is withdrawn before the start of the program, a $35.00 USD processing fee will be assessed. All Payments are to be paid in full by July 15, 2020 via CashApp $MMDA19. By selecting "AGREE" below, you are providing your digital signature in agreeance to the aforementioned MMDA terms.
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