Make Dance Your Reality - Waiver
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Hello and Welcome to “Make Dance Your Reality" programs 2026. We can’t wait to share what we have in store for you! Please take a moment to fill out our Waiver Document so we can ensure the best and safest experience for you.
Dancers Information
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Medical Information
Medical Allergies/ Medications
*
Indicate Non Applicable or provide details
Medical Details
*
Indicate Not Applicable or Provide any Medical or other details we should know about
Emergency Contact Information
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Email
*
example@example.com
Emergency Contact Address
*
Street Address
Street Address Line 2
City
Province
Postal / Zip Code
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Alternate Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact - Relationship to Dancer
*
Parent/Guardian Information
Only required if Dancer is under 18 years of age
Parent/ Guardian Information if Dancer is under 18 years of age
Same as Emergency Contact
Other
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Email
example@example.com
Parent/Guardian Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If other - Parent/Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Important Waiver Infomation
PLEASE READ .....
Waiver - Understand the following: I recognize that dance is physical and athletic art form that comes with risks. I agree to accept all risks, dangers,hazards and take responsibility for any losses, damages and/or injuries resulting throughout the course of the event. I agree I will not bring any legal action against the members of Make Dance Your Reality - Lindsay Aquin, or it’s venue, for any losses, damages and/or injuries resulting from andy of the events of Make Dance Your Reality.
*
Yes - Understand
Waiver Understanding: The signer also recognizes the intellectual property and choreography presented at any of the events presented by Make Dance Your Reality is solely for the purposes of the workshop and not to be presented at any public forum without the permission of the teacher/director and/or choreographer.
*
Yes - Understand
Waiver Understanding: By participating in MDYR events, I acknowledge and agree that any photographs, videos, or other media taken during the event are the property of Make Dance Your Reality (MDYR). MDYR reserves the right to use these materials for promotional purposes at their discretion.
*
Yes - understand
Dancers Signature
*
Date
-
Month
-
Day
Year
Date
Parent/Guardian Signature (where applicable)
Date
-
Month
-
Day
Year
Date
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