Please print off a copy of this document. The Liability Waiver, Media Consent Form, and the Health Information of the student must be handed in prior to starting a class.  Please provide a completed form for each individual student.

 

 

Name of Dancer: __________________________________________       Age: ________

 

Birth Date: ___________ / ___________ / ___________

 

Address: ____________________________________________________________________

 

City: _____________________________  Province: _________________________________

 

Phone: ___________________________  Email: ____________________________________

 

Emergency Contact Name: ______________________________________________________

 

Emergency Phone: ________________________________________

 

 

Liability Waiver:

 

The student _________________________________ (or if under 18 years old the parent/legal guardian) understands that dance includes physical movement as well as many other positive factors.  As with any physical activity the risk of injury (even serious or disabling) is always present and cannot be entirely eliminated.  If the student experiences any pain or discomfort, they will listen to their body, discontinue the activity, and ask for support from the instructor(s).  The student will assume full responsibility for any and all injuries, which may occur with participation. By signing this form, the student has been verified to participle in such fitness, with their health and medical conditions being taken into account.  They will make the instructor(s) aware of any medical conditions or physical limitations before class. I hereby agree to irrevocably reveal and waive any claims that I have now or may have hereafter against Flourish Studios and its instructors/owner.

 

I have read and fully understand and agree to the above terms of this Liability Waiver Agreement.  I am signing this agreement voluntarily and recognize that my signature serves as complete and unconditional release of all liability.

 

 

Student  (Printed): _____________________________________________________________

 

                                                            (OR if under 18 years old)

 

Parent/Legal Guardian (Printed): __________________________________________________

 

 

 

Signature: ___________________________________________________________________

 

 

Date: Birth Date: ___________ / ___________ / ___________

 

 

 

Media Release Form:  

 

During the dance season, your child may be photographed/videoed.  With your consent, the content may be released for the use of newspapers, brochures, videos, our website, social media accounts for the studio, etc.

Please indicate your preference below.

 

• YES     Photographs/videos of my child may be released for use in the media.

 

• NO     Photographs/videos of my child may not be released for use in the media.

 

 

 

Health Information:

 

All information will remain confidential and only to be shared with staff who will be working with your child or yourself for safety reasons if it is applicable.  Please share what is necessary for us to be aware of or you feel is important to document. 

 

List of medications:

 

____________________________________________________________________________

 

____________________________________________________________________________

 

____________________________________________________________________________

 

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Allergies: Please include name/type of allergy, reactions, and treatment below. 

​

____________________________________________________________________________

 

____________________________________________________________________________

 

___________________________________________________________________________

 

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Health History: (Please check conditions your child has or has had)

 

• ADD/ADHD

• Arthritis/Joint Issues

• Asthma

• Blood disorders

• Bowel/bladder problems

• Developmental delays

• Diabetes __ T1 __ T2

• Fainting/dizziness

• Hearing impairment

• Heart condition

• Hepatitis/HIV

• Hospitalizations

• Learning disability

• Menstrual problems

• Mental health condition

• Migraines

• Physical limitations

• Seizures, tics, or tremors

• Serious illness:______________________________________

• Visual impairment

• Other: _____________________________________________

• Any previous injury? _________________________________