Medical/Liability Wavier

Medical/Liability Wavier
School of Dance & Gymnastics 210 Moseley Rd Byron, GA 31008

Medical and Liability Release Parent/Guardian's Agreement
Students First & Last Name
Age
Date of Birth

MonthDayYear
Date
Sex
Student's Address
Father/Guardian Information

First NameLast Name
Address
Phone Number
Mother/Guardian Information

First NameLast Name
Address
Phone Number
Please enter a valid phone number.
The child named above will be permitted to take part in dance and gymnastics activities offered by Ms. Patricia's. I/We release Ms. Patricia's School of Dance & Gymnastics, proprietors, instructors and sponsors from any liability of above student, to us, or to either of us as parents/guardians for injury to above student and further agree to indemnify Ms. Patricia's School of Dance & Gymnastics, proprietors, instructors and sponsors against all loss and liability which they may incur or become responsible for, arising by virtue of above student's participation in such activities and athletics.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Email
example@example.com
I/We have completed all registration, medical & liability release forms.
Signature of ParentGuardian

Clear
Date

MonthDayYear
Date
Person Responsible for Tuition
Emergency Contact(s) other than Parent or Doctor
Name
Address
Phone Number
Please enter a valid phone number.
Name
Address
Phone Number
Please enter a valid phone number.
Photography Waiver
I am granting permission for my child to be filmed, videotaped, audiotaped or
photographed and are granting full use of the likeness, voice, and words without
compensation.
I have read and understood this waiver and affix my name in agreement.
Please Type Your Child’s Name and Your Name As Proof Of Signature and Acceptance of
this Release Form:
Child's Name

First NameLast Name
Parent or Guardians Signature

Clear
Date

MonthDayYear
Date
Tuition is due by the 10th of each month. After the 20th, a late fee of $25 will be due. If not paid by then, the student will not be allowed to attend until the account is current. If not paid, the balance due will be turned over to a collection agency.
Should be Empty:

Medical/Liability Wavier

Emergency Contact(s) other than Parent or Doctor

Photography Waiver