Diverse Dimensions Dance Center Waiver
Jun 24, 2025 03:29 AM
I hereby state, acknowledge and agree as follows:
1. Personal Information.
Complete Name (First, Middle Initial, Last): ___________________________________
Name of Parent/Legal Guardian (First, Middle Initial, Last): ______________________
Address: _______________________________________________________________
City: ________________________________State: _____________Zip: ___________
Day Phone: __________________________Night Phone: ________________________
Email: __________________________________Date of Birth: ___________________
Insurance Company: ______________________Medical Allergies: ________________
Doctor Name: _____________________Doctor Phone Number: __________________
2. Medical Release.
A. I understand that by participating in Miss Monica’s Quinceanera Choreography, Miss Monica Sanchez, and Diverse Dimensions Dance Center, there is a possibility of injury or sickness to me/my child. I hereby give my permission/permission for my child to participate in dance choreography with Miss Monica’s Quinceanera Choreography, Miss Monica Sanchez, and Diverse Dimensions Dance Center and do hereby authorize 911 medical staff members and hospital staff members to administer immediate treatment to my child in the event of injury or sickness.
B. I agree to follow all rules, regulations, and guidelines, including safety and
security rules. I understand and acknowledge and hereby, for my minor child, my heirs, RELEASE, DISCHARGE, INDEMNIFY AND HOLD HARMLESS Miss Monica Sanchez
(collectively, the “Releasees”), from and against all losses, claims, damages, liabilities, costs or expenses (collectively, “Losses”), arising in whole or in part, directly or indirectly, from my minor child’s participation in dance choreography including, but not limited to, any
Losses caused or alleged to be caused in whole or in part by the negligence of any Releasee. The foregoing release includes, without limitation, all liability, bodily injury, death, loss or damage to my minor child or any third party arising in whole or in part, directly or indirectly, from such participation in dance choreography with Miss Monica’s Quinceanera Choreography, Miss Monica Sanchez and Diverse Dimensions Dance Center.
I further covenant not to sue any of the Releasees with respect to any matter addressed by this release.
3. Publicity Release.
Except where prohibited by law, I hereby irrevocably grant to Miss Monica’s Quinceanera Choreography, Miss Monica Sanchez, and Diverse Dimensions Dance Center and its parent companies, successors and assigns, the absolute right and permission to use my name, photograph, video, for promotional purposes in any manner or media whether now existing or hereafter created (including, without limitation, in publications and online), worldwide, in perpetuity, without notice to me and without limitation, condition, consideration, consent or compensation. I shall have no right of approval, no claim to any compensation, and no claim arising out of the use, alteration, distortion or illusionary effect or use in any composite form of any of the foregoing attributes of my identity.
I HAVE READ THIS RELEASE, UNDERSTAND THAT I HAVE GIVEN UP
CERTAIN RIGHTS BY SIGNING IT AND HAVE SIGNED IT FREELY AND WITHOUT
ANY INDUCEMENT OR ASSURANCE OF ANY NATURE AND INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW.
I acknowledge and agree that I have read this release prior to its execution, and that I fully understand its contents.
Parents Name ______________________________________ _____________________
Childs Name _______________________________________________________________
Date _______________________________________________________________________