Art in Motion Pittsburgh Student Contact Form
Please fill out this form even if you are already enrolled. We are creating a new database for emergency situations, last minute cancellations due to weather, and to keep our insurance forms up to date! We will not release this information to anyone! Thank you in advance!
Name of Dancer(s)- if more than one student please enter all names separated by a comma *
Parent/ Guardian Name (if applicable)
Email *
Address
Phone number *
Dancer's Date of Birth *
Studio Policy: I understand and agree that in participating in any dance class, workshop, rehearsal or performance, there is a possibility of physical injury or death. I voluntarily agree, therefore, to assume all risks and responsibility for any such injury or accident, which might occur to me or my child during any of Art in Motion Pittsburgh, LLC classes, rehearsals, performances, or activities. I also exempt, release, and indemnify Art in Motion Pittsburgh, LLC, its owners, agents, volunteers, assistants, employees, guest artists, faculty members, and/or students from any and all liability claims, demands, or causes of action whatsoever from any damage, loss, injury, or death to me, my children, or property which may arise out of or in connection with participation in any classes or activities conducted by Art in Motion Pittsburgh, LLC. All tuition is NON –REFUNDABLE, NON-TRANSFERABLE and due by the 10th of every month. PLEASE see Ms. Jen or Ms. Lucy about payment options. Please initial below. *
I allow Art in Motion Pittsburgh to photograph my child/myself in classes and showcases and to use for promotional purposes. Please initial if you agree. *
Please list any allergies or medical conditions we should know about your child EXAMPLE: Asthma, Peanut allergy etc.
Which class are you interested/ currently enrolled in?
How did you hear about us? Friend, website, google search, facebook ad, instagram, etc?
Liability Waiver Art in Motion Pittsburgh, LLC ASSUMPTION OF RISK, WAIVER OF LIABILITY, AND INDEMNIFICATION RELATING TO COVID-19 (Please read the following and initial, thank you!)
COVID-19 is a contagious disease and the Centers for Disease Control and Prevention (CDC), as well as federal, state, and local governments have issued, and may be continuing to issue, changing regulations and guidelines. As a result, those participating in Art in Motion PGH’s in-person group and/or private dance classes (whether in studio or off- site), specialty workshops, and/or other activities (collectively, “Dance Classes”) must acknowledge their understanding of the additional risks to attendance and participation. Art in Motion PGH has put in place reasonable preventative measures to reduce the spread of COVID-19; however, Art in Motion PGH cannot guarantee that you will not become infected with, contract, or spread COVID-19. Therefore, in consideration for your attendance in dance class, you understand, acknowledge, and agree to the following: By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by attending dance classes and that such exposure or infection may result in personal injury, illness, permanent disability, or death. I understand that the risk of becoming exposed to or infected by COVID-19, and the risk of spreading it to others, may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Art in Motion PGH employees, agents, contractors, representatives, and other attendees, customers, or clients, and their families or other persons with whom they have had close contact. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my attendance at Dance classes (“Claims”). Further, I agree, warrant, and represent that I shall not participate in Dance classes if (i) I experience any symptoms of COVID-19, including, but not limited to, fever, shortness of breath, or cough, and/or (ii) I have a suspected, confirmed, and/or diagnosed case of COVID-19. I hereby release, covenant not to sue, discharge, and hold harmless Art in Motion PGH, its employees, agents, contractors, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of Art in Motion PGH, its employees, agents, contractors, and representatives, whether a COVID-19 infection occurs before, during, or after attendance at Dance classes. I agree to indemnify, defend, and hold harmless Art in Motion PGH, and its employees, agents, contractors, and representatives (“Released Parties”) from and against any and all costs, expenses, damages, claims, lawsuits, judgments, losses, and/or liabilities (including attorney fees) arising either directly or indirectly from. or related to, any and all claims made by or against any of the Released Parties due to bodily injury, death, loss of use, monetary loss, or any other injury from or related to me, whether caused by the negligence of the Released Parties or otherwise specifically related to my attendance of Dance classes. I warrant and represent that (1) I read this Assumption of Risk, Waiver of Liability, and Indemnification; (2) I understand it; (3) I am sufficiently informed about the risks involved, the waiver of liability, and the indemnification required to decide whether to sign this document; and (4) I sign it voluntarily as my own free act and deed. I agree that no oral or written promises, representations, statements, or inducements, apart from this written agreement, have been made to me regarding this Assumption of Risk, Waiver of Liability, and Indemnification. I agree that this Assumption of Risk, Waiver of Liability, and Indemnification is governed by, and is to be construed in accordance with, the laws of the Commonwealth of Pennsylvania. If any of the provisions this Assumption of Risk, Waiver of Liability, and Indemnification are found to be unenforceable, the remainder shall be enforced as fully as possible, with the unenforceable provision(s) to be modified to the extent to allow it to be enforceable by law. I, intending to be bound, represent that I am fully competent and signing this Assumption of Risk, Waiver of Liability, and Indemnification for full, adequate, and complete consideration *
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