Madison Contemporary Dance (MCD) Summer Intensive Registration 2020
Dancer's First Name *
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Dancer's Last Name *
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Age *
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Date of Birth *
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Academic School *
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Academic Grade *
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Parent/Guardian Name *
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Street Address *
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City *
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State *
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Zip Code *
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Phone Number *
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Cell Phone Number (if different)
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Parent/Guardian Email *
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Student Email
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Emergency Contact Name *
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Emergency Contact Phone Number *
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Doctor Name *
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Doctor Phone Number *
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Styles of Dance Studied *
Please indicate years of study for each style
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Current Dance School(s) *
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How did you hear about the MCD Summer Intensive? *
Please choose as many as apply: Dance teacher name, Madison Community Dance Newsletter, Flyer, E-mail, Facebook, Dance School, Word of mouth, Other
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Dance Goals *
Goals for this summer
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Dance Goals *
Future dreams and goals
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Do you have an exercise ball you can bring for progressive ballet class? *
Electronic Signature *
MADISON CONTEMPORARY DANCE - This registration must be signed for participation. I certify that the above-named student is in good health and capable of participating in dance rehearsal and performance. As the legal parent or guardian, I release and hold harmless Madison Contemporary Dance, it’s directors, board and operators from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while in or upon the premises or any premises under the control of Madison Contemporary Dance, it’s owners and operators or in route to or from any said premises. A STEP ABOVE DANCE & MUSIC ACADEMY - As the legal parent or guardian, I release and hold harmless A Step Above Music and Dance Academy, it’s owners and operators from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while in or upon the premises or any premises under the control of A Step Above Dance & Music Academy, it’s owners and operators or in route to or from any said premises. PHOTO RELEASE - I give permission to use photographs and video taken at the Madison Contemporary Dance Summer Dance Concert for Madison Contemporary Dance advertisement materials and website. Model Release for Minors: For good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, I hereby grant to: (the MCD “Photographer”), her heirs and legal representatives the irrevocable and unrestricted right and permission to copyright, in her own name or otherwise, and use, re-use, publish and re-publish photographic portraits or pictures of me or in which I may be included, in whole or in part, as part of a composite or distorted in character or form, without restriction as to changes or alterations, in conjunction with my own or a fictitious name, or reproductions thereof in color or otherwise, made through any medium at her studios or elsewhere, and in any and all media now or hereafter known for illustration, promotion, art, editorial, advertising, trade, publishing, or any other purpose whatsoever (except pornographic or defamatory). I also consent to the use of any printed matter in connection therewith. I hereby waive any right that I may have to inspect or approve the finished product or products and the advertising copy or other matter that may be used in connection therewith or the use to which it may be applied. I hereby release, discharge, and agree to save harmless the Photographer, her heirs, legal representatives and assigns, and all persons acting under her permission or authority or those for whom she is acting from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise that may occur or be produced in the taking of such photographic portraits or pictures or in any subsequent processing thereof, as well as any publication thereof, including without limitation any claims for libel or invasion of privacy. I have read the above authorization, release, and agreement, prior to its execution, and I am fully familiar with the contents thereof. This release shall be binding upon me and my heirs, legal representatives, and assigns. I represent that I am the [parent/guardian] of the above-named model. For value received, I hereby consent to the foregoing on his/her behalf.
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Please pay tuition on the bottom of the page https://www.madisoncontemporarydance.com/summer-intensive *
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