The World Health Organization has declared the novel Coronavirus (COVID-19) a worldwide pandemic. Due to its capacity to transmit from person-to-person through respiratory droplets, the government has set recommendations, guidelines, and some prohibitions which Studio 85 Dance Center, LLC. adhere to.

In consideration of my participation in the foregoing, the undersigned acknowledge and agree to the following:
___I have not experienced symptoms that of fever, fatigue, difficulty in breathing, or dry cough or exhibiting any other symptoms relating to COVID-19 or any communicable disease within the last 14 days.
___I have not, nor any member(s) of my household, traveled by sea or by air, internationally within the past 30 days.
___I did not, nor any member of my household, visit any area within the United States that was reported to be highly affected by COVID-19, in the last 30 days .
___I have not been, nor any member(s) of my household, diagnosed to be infected of COVID-19 virus within the last 30 days.

Following the pronouncements above I hereby declare the following:
___I am fully and personally responsible for my own safety and actions while and during may participation and I recognize that I may be in any case be at risk of contracting COVID-19.
___With full knowledge of the risks involved, I hereby release, waive, discharge Studio 85 Dance Center, its owner, officers, and employees from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by me related to COVID-19 while participating in any activity while in, on, or around the premises or while using the facilities that may lead to unintentional exposure or harm due to COVID-19.
___I agree to indemnify, defend, and hold harmless Studio85 Dance Center from and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against any of the released party due to injury, loss, or death from or related to COVID-19.

By signing below I acknowledge that I have read the foregoing Liability Release Waiver and understand its contents; that I am at least eighteen (18) years old and fully competent to give my consent; I have been sufficiently informed of the risks involved and give my voluntary consent in signing it as my own free act and deed; I give my voluntary consent in signing this Liability Release Waiver as my own free act and deed with full intention to be bound by the same, and free from any inducement or representation.
This waiver will remain effective until laws and mandates relevant to COVID-19 are lifted.
Printed Name______________________________
Signature______________________________ Date_________

Please list any allergies and symptoms your child may have:
________________________________________________________________
________________________________________________________________
Do you give Studio 85 Dance Center permission to display your child’s allergies and symptoms in the studio? Yes No
May we call 911 in case of an emergency to be transported by ambulance and receive medical attention at the nearest hospital?
Yes No Initial _____
May we transport your child ourselves to the nearest hospital or fall-out shelter in case of an emergency by car?
Yes No Initial _____

Emergency Contacts (parents will always be contacted first):

Name___________________Relationship___________Phone______________

Name___________________Relationship___________Phone____________
Does your child have previous dance experience?
Yes No
If so, please list reason(s) for leaving previous studio
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

Parent/Guardian Signature ________________________________ Date _______

Student Information

Student’s Name: _______________________________ Date of Birth (MM/DD/YYYY): ______________
Mailing Address: ______________________________________________________________________
Primary Phone: ________________________________ Phone (2): _____________________________
Name of Person responsible for paying fees: ________________________________________________
Primary Email Address: _________________________________________________________________
Primary Billing Phone # ______________________________
Legal Release and Policy Acceptance (please initial)
___ I/we understand my billing obligations
___ I/we understand the risks related to dance ___ I/we understand my responsibilities for my property
___ I/we understand the dress code ___ I/we understand the schedule
___ I/we give media use rights permission ___ I/we understand the attendance policy

___________________________________ ______________________________
Signature / Responsible Party Date
Classes

Registration Fee: _______________ Recital Fee: ______________
Tuition: _______________ Costume Fee: ______________
Discounts: _______________
Total Monthly Tuition _______________
Medical
Allergies: ____________________________________________________________________________
Will your child require any special medical attention during a normal class: (yes/no) __________________