New Student Details
All adult Students OR Parents/Guardians of Minor/Adult with Disability must review and sign.
Name of Student
Name of Parent (for MINORS only)
Address (must be physical, no P.O boxes accepted)
Date of Birth
Active Adult (55+)
Phone # Cell or Home Primary Number
Phone # (Secondary)
Phone # (EMERGENCY contact)
Emergency Contact Name
Emergency Contact Relationship to Student
Any Health concerns/injuries/ specific details of past injury if any/ current health disorders
Are you (person filling the form) at least 18 years old?
Pictures or video may be taken of participant for use in program or publicity of IDEA. Please check ONLY if you do not approve
DO NOT APPROVE
Location : (Check all that apply): Morrisville
Brier Creek, RALEIGH
Styles: (Check all that apply): Bollywood Dance
FOLK DANCES of India
KATTHAK (Classical Dance Form)
GOALS: (Check all that apply)
PARTICIPATE IN PERFORMANCES
LEARN TO DANCE (various levels)
ASSUMPTION OF RISK & RELEASE OF LIABILITY : I request permission to participate in fitness activities and classes led, assisted, provided, or facilitated by Indigo Dance Evolution Academy D/B/A Priya Chellani. I voluntarily acknowledge that participation is expressly conditioned on my agreement to each of the terms of this document. I agree as follows: I understand that physical exercise, dance classes, and fitness activities may cause injury, and that I am voluntarily assuming all inherent risk of injury when participating in such activities and classes, (hereinafter “Activities”) that are led, assisted, provided, or facilitated by Indigo Dance Evolution Academy D/b/a Priya Chellani, and its instructors and/or employees. I recognize and acknowledge that participation in these Activities involves risks of physical injury. I agree to assume the full risk of any injuries (including death), damages, or loss that I may sustain as a result of participating in any and all Activities arising out of, connected with, or in any way led, assisted, provided, or facilitated by Indigo Dance Evolution Academy D/B/A Priya Chellani and its instructors and/ or employees including for negligence, and the condition of equipment and premises. I do hereby fully release and discharge Indigo Dance Evolution Academy D/B/A Priya Chellani and their agents, employees and the sponsors, and those whose facilities are being used (the “Released Parties”) from any and all liability, claims, and causes of action, including negligence, for injuries or illness (including death), damages or loss which I may have or which may accrue to me on account of participation in the activities mentioned above. This is a complete and irrevocable release and waiver of liability. I covenant not to sue the Released Parties for any alleged liabilities, claims, or causes of action released hereunder. I further agree to indemnify and hold harmless and defend the Released Parties from any and all claims resulting from injuries or illness (including death), damages, or loss, including, but not limited to attorney’s’ fees, sustained by me arising out of, connected with, or in any way associated with participation by me in the Activities mentioned above. In the event of any emergency, where I am incapacitated to make a medical decision for urgent treatment of my condition, I authorize the Released Parties to secure from any licensed hospital, physician and/or medical personnel any treatment deemed necessary for the immediate care to me and agree that I will be responsible for payment of any and all such medical services rendered. I have been advised by the Released Parties to consult with a physician before I undertake any physical exercise program. I certify that I am in good health and in sufficient physical condition to properly and safely participate in the Activities mentioned above. I read and fully understand this acknowledgement, assumption of risk & release of liability; i agree to be fully bound by its terms. I realize I am subject to injury from these activities and no form of preplanning can remove all of the danger to which i am exposing myself; I assume all risks inherent in my participation. I voluntarily agree to the above waiver and release of liability and assume all risks incidental to all constituents (“Released Parties’) of Indigo Dance Evolution Academy D/B/A Priya Chellani. I date & sign as below:
Send me a copy of my responses.
Page 1 of 1
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service