impact performing arts
2019 August Pom Clinic Registration Form
Dancer's First and Last Name *
Your answer
Dancer D.O.B *
MM
/
DD
/
YYYY
Parent/Guardian First and Last Name *
Your answer
Parent/Guardian Email *
Your answer
Cell Phone Number *
Your answer
School Attending *
Your answer
How Did You Hear About Impact? *
Your answer
Any Injuries or Illnesses? *
Your answer
Wavier
Participation in any Impact Performing Arts activity on or off site, and use of recreational facilities involves risk of accidental injury despite all safety precautions. Having been informed of the activities conducted by Impact Performing Arts, I/we, as individual or as a parent or guardian of the participants named herein, assume all risks and hazards incidental to the activities, and release from responsibility and agree to indemnify and hold harmless Impact Performing Arts, its officers, directors, independent contractors, volunteers and all employees for any illness or injury to me or my child or family members accruing during his/her/our participation in any activity or use of any recreational facility at or conducted by Impact Performing Arts. I also agree to the use of my child’s photo/video for Impact Promotional purposes.

Printing name below will serve as your signature.

I agree to the wavier above. Parent/Guardian (Print Name) *
Your answer
Payment Options *
Questions
Please call or email with any questions or concerns. (240)-340-1635 or info@impackpak.com
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