Registration Form & Liability Waiver

1
Date
Month
Day
Year
2
Student Name
First Name
Last Name
3
Student Information
Dancer Name
Local Address (City, State, Zip Code)
Allergies?
Home Phone
Work Phone
Cell Phone
Email Address
4
COVID-19 RELEASEI acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that En Pointe Inc., DBA En Pointe Dance & Fitness has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19. I further acknowledge that En Pointe Inc., DBA En Pointe Dance & Fitness can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, studio staff, and other studio clients and their families. I voluntarily seek services provided by En Pointe Inc., DBA En Pointe Dance & Fitness and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending class. I attest that: * I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell. * I have not traveled internationally within the last 14 days. * I have not traveled to a highly impacted area within the United States of America in the last 14 days. * I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19. * I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities. * I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19. I hereby release and agree to hold En Pointe Inc., DBA En Pointe Dance & Fitness harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the studio or that may otherwise arise in any way in connection with any services received from En Pointe Inc., DBA En Pointe Dance & Fitness. I understand that this release discharges En Pointe Inc., DBA En Pointe Dance & Fitness from any liability or claim that I, my heirs, or any personal representatives may have against the studio with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from En Pointe Inc., DBA En Pointe Dance & Fitness. This liability waiver and release extends to the studio together with all owners, partners, and employees.
YESNO
5
Emergency Contact Information
Contact Name
Relationship to Student
Home Phone
Work Phone
Cell Phone
Email Address
6
How did you hear about our studio?
Huge
Large
Normal
Small
Ok
Ok
7
Please list any prior dance experience (i.e. number of years, dance technique studied, teachers, etc.):
Huge
Large
Normal
Small
Ok
Ok
8
LIABILITY RELEASEIndicated in the space below are any health problems or conditions of which the studio should be aware (such as heart, back, medical, allergy, muscular, pregnancy, diabetes, epilepsy, chemical or neurological condition, special medication, knee/kidney/shoulder problems, etc.). I understand that risk of injury is inherent in any physical activity and I knowingly and voluntarily accept that risk. I, the undersigned, for myself, my heirs, administrators, and executors, herby waive and release En Pointe Dance & Fitness, individually and , En Pointe Inc. and its staff from any and all claims or damages of any kind arising out of my participation in the exercise and/or dance program of En Pointe Dance & Fitness. I certify that I am in proper physical condition to participate in the exercise/dance program and that I have been examined by a licensed physician and found to be in proper physical condition to participate in said program. I, the undersigned, do herby authorize En Pointe Dance & Fitness or her designated agents (being teachers or administrators employed by En Pointe Dance & Fitness.) to obtain medical treatment for myself in emergency situations if needed. I understand that I am responsible for any medical expenses and that the absence of health insurance does not make release En Pointe Dance & Fitness responsible for payment of medical expenses. This authority includes the power to authorize any and all treatment deemed necessary under the circumstances by a licensed physician. This power is in essence a power of attorney and shall remain in effect for one year from the date signed below. Permission is granted to En Pointe Dance & Fitness to use photographs of myself or my child for publicity purposes. I have read, understood and agree to be bound by the above statement and have been given a copy of En Pointe Dance & Fitness Studio Policies and Dress Code ( please print your name, sign & date.)
Clear
Should be Empty: