Pirouette Fitness Subscription Program
Please complete form in its entirety to join our Fitness Subscription Program
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Full Name *
Address *
Phone number *
Email Address *
PACKAGE OPTIONS: We will be offering three packages. Please select your option below. *
PAYMENT: You are authorizing Pirouette Dance Academy to charge a card of your choice on the first of every month. If the first falls on a Sunday or a Holiday, it will be charged the following day. Fee stays the same every month regardless as to how many classes we have or if you attend. *
CANCELLATION: You must notify Pirouette Dance Academy by the 25th of the month prior if you wish to terminate your subscription. Subscription is on a month to month basis with no cancellation fee and no term. *
CREDIT CARD INFORMATION: By submitting your credit card information you are authorizing Pirouette Dance Academy to keep your information on file and charge your card every month until you cancel. *
Cardholder Name *
Credit Card Number *
Expiration Date *
Billing Zip Code *
WAIVER & RELEASE OF LIABILITY: I, the undersigned, hereby expressly and affirmatively state that I wish to participate in the Fitness class instructed by staff or other licensed instructor at the Pirouette Dance Academy, INC, 1706 President Ave., Fall River, MA or virtually from a place of my choice. I understand that it is my responsibility to consult with a physician prior to participating in the Fitness class. I attest that I am physically fit and have no pre-existing conditions that would prevent me from fully participating in Fitness class. I realize that my participation in this activity involves risks of injury, including but not limited to muscle strain, joint sprains, broken bones, slips, trips, falls, heart attack, stroke, and even the possibility of death. I also recognize that there are many other risks of injury including serious disabling injuries, which may arise due to my participation in this activity, and that it is not possible to specifically list each and every possible injury risk. Knowing the material risks and appreciating, knowingly and reasonably anticipating that other injuries and even death are a possibility, I hereby expressly assume all of the delineated risks of injury, all other possible risks of injury, which could occur by reason of my participation. I subjectively understand the risk of my participation in this activity, and knowing and appreciating these risks, voluntarily choose to participate, assuming all risks of injury or even death due to my participation. I, my heirs or my legal representative acting on my behalf do hereby waive, release, and forever discharge the Pirouette Dance Academy, INC, all Pirouette Dance Academy, INC employees, representatives, and all others from any and all responsibilities or liability for injuries or damages resulting from my participation in this activity and loss/damage to any personal items. I give permission for medical treatment to be administered in an emergency. This agreement is valid for the duration of your participation in Fitness classes at Pirouette Dance Academy, INC.I understand that all Dance Choreography at Pirouette Dance Academy, INC has been either licensed by ZUMBA to Pirouette Dance Academy, INC or has been personally created by Pirouette Dance Academy, INC for sole use in their ZUMBA fitness classes. As such, I realize that all Dance Choreography is licensed by ZUMBA is the sole property of ZUMBA and its licensees. Similarly, all original Dance Choreography created by Pirouette Dance Academy, INC staff for its fitness classes is the sole property of Pirouette Dance Academy, INC. Use of the Dance Choreography of Pirouette Dance Academy, INC is prohibited. I agree not to engage in any unauthorized use of such Dance Choreography from the Pirouette Dance Academy’s ZUMBA fitness program without a license from ZUMBA, license from American Society of Composers, Authors and Publishers (ASCAP) and written consent of Pirouette Dance Academy, INC management. Unauthorized use is any use outside the dance studio not expressly permitted by Pirouette Dance Academy, INC including but not limited to incorporating in whole or in part any of the Dance Choreography and music used by the Pirouette Dance Academy, INC staff in any other class. I understand that I will be prosecuted to the full extent of the law, both civilly and criminally, should I engage in any unauthorized use of the Pirouette Dance Academy, INC and ZUMBA Dance Choreography. *
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