OMA Dance Registration, Release & Terms of Agreement
Dancer Name (first and last)
T-Shirt Size *
Youth Extra Small
Parent/Guardian Phone Number
Emergency and Medical Info
*It is the responsibility of the parent(s) or guardian(s) to inform OMA Dance, as well as the instructor, of any illness or injury that should limit their child’s participation in specific physical activities.*
Please list any authorized person(s) to be called in case of an emergency: (name, number & relationship)
Please specify any physical or mental conditions or any physical activities your child should be restricted from. Also, provide the name and purpose of medications taken. If this does not apply please respond "doesn't apply"
List all persons authorized to pick up children from the dance center. (name, number, & relationships)
Consent, Authorization and Release
NOTICE: Before participating in this or any physical activity parents should consult a physician on their child’s behalf.
VOLUNTARY PARTICIPATION: I, _____________________________________, acknowledge that I have voluntarily chosen and request for my child/children,________________________________, to participate in the physical activity sponsored by City Arts 2, Organic Movement Atelier and Aliyah Johnson Williams.
ACKNOWLEDGEMENT: I am aware that participation in the physical activity may be hazardous. I acknowledge that a certain minimum level of physical health, strength, fitness and flexibility may be required. I represent that my child/children possess the level of health necessary to participate in these activities. My child/children are voluntarily participating in these activities with knowledge of the risks of injury. I assume all responsibility and liability for any and all injuries my child/children may sustain due to my participation in these activities.
RELEASE: In consideration for being permitted to participate in the class, workshop, event or physical activity, I agree that I, my children, heirs, assignees, guardians and legal representatives will not make any claim against, sue, or attach the property of any of the hosts, instructors, organizers, or participants in the class, workshop, event or physical activity including but not limited to Aliyah Johnson Williams and City Arts 2 for injury or damage resulting from my child/children’s participation. I release all such hosts, instructors, organizers, and participants, their agents and heirs from any and all actions, causes of action, lawsuits, claims, or demands that I, my assignees, heirs, guardians and legal representatives, now have or hereafter may have for any and all injury, illness, loss of or damage to property associated with my participation in the class, workshop, event, or physical activity. I have carefully read this agreement and fully understand its contents. I have signed this release form freely and voluntarily. I am aware and agree that it is a complete release of liability for any injuries or damages that I or my child/children may sustain due to transportation, classes, workshops, events, and physical activities with Aliyah Johnson Williams, City Arts 2 and all such hosts, instructors, organizers and participants. I agree with these terms.
I accept and agree to the terms above.
I hereby grant permission to Organic Movement Atelier by Aliyah Monea' to use photographs and/or video of my child/ children, in publications, news releases, online and in other communications related to the mission of Organic Movement Atelier by Aliyah Monea.'
I accept and agree to these terms.
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