Waiver and Consent Form

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Please complete this waiver and consent form in order to participate any activity or class at Kicks Academy of Dance (ABM Dance, LLC).

Email *

Record my email address with my response

Student First Name *

Student Last Name *

Birthdate *

YYYY

Age *

Street Address *

City *

State *

Zipcode

Are there any health concerns or allergies the studio ad staff should be aware of? *

Yes

If yes, please explain:

Mother's/Guardian #1 Name (first and last) *

Mother's/Guardian #1 Cell *

Mother's/Guardian #1 Email *

Father'/Guardian #2 Name

Father's/Guardian #2 Cell

Father's/Guardian #2 Email

Student's Cell

Student's Email

Other Contact info

Emergency Names and Contacts *

I, the undersigned, hereby acknowledge that certain risks of injury are inherent to participation in these dance related physical activities. These risks and dangers may be other caused by the action, inaction or negligence of the participant and others. There may be other risks not know or reasonably foreseeable at this time. I accept and assume such risks and responsibility for the loses and/or damages following such injury, however caused, and whether caused in whole or in part by the negligence of the named student above. If the student has a temporary restriction (sickness, sprain, soreness, etc.) I will inform the appropriate instructor on a daily basis in writing. I agree that the student and I will abide by the rules of Kicks Academy of Dance ("KICKS"). I consent to the student's participation in KICKS physical programs, classes and activities. Recognizing the possibility of physical injury associated with these programs, classes and activities, and in consideration for KICKS accepting the student for its programs, classes and activities, I hereby release, discharge, indemnify, and hold harmless KICKS, its affiliated organizations, and their employees, teachers/subcontractors and associated personnel from and against any and all claims by or on behalf of the student as a result of the student's participation in the programs, classes and activities. In my absence, I also request KICKS, through its staff, to obtain emergency medical care in the event that such care is necessary or appropriate in the opinion of the staff for the benefit of the student due to accident or illness. I agree to pay any treatment costs directly to the hospital, physician, or laboratory providing such care upon presentation of the bill to me.

I agree

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Electronic Signature (Parent/Guardian) & Date *

Electronic Signature (Student) & Date *

Photo Release - I, the undersigned, give permission for KICKS and their staff to photograph the above named student during classes or performances to be used for studio displays and promotional material such as all forms of social media. *

Yes, I give KICKS and their staff permission to photograph the above named student.

No, I do NOT give KICKS and their staff permission to photograph the above named student.

Video Release - I, the undersigned, give permission for KICKS to video the above named student during classes and performances to be used for studio displays and promotional material such as all forms of social media. *

Yes, I give KICKS and their staff permission to video the above named student.

No, I do NOT give KICKS and their staff permission to video the above named student.

A copy of your responses will be emailed to .

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