Mandala Academy Liability Form

Mandala Academy Participant Information & Liability Waiver

This form must be completed before a participant attends any Mandala Academy class, workshop, camp, rehearsal, performance, or related activity.
Signer Information (Parent/Guardian or Adult Participant)
Who are you registering?
Signer’s Full Legal Name

First NameLast Name
Signer’s Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Signer’s Email Address
example@example.com
Signer’s Relationship to Participant
Emergency Contact

Please provide someone other than the signer named above.
Emergency Contact’s Full Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship
Participant Information
Participant’s Full Legal Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Dancer's Age & Grade (for the 26-27 school year)
Grade (if applicable)
Allergies, Medical Conditions, Injuries, Activity Restrictions, Accessibility Needs, or Emergency Medications
Enter None if there are none.
Anything Else You Would Like Us to Know?
Tell me a bit about you/ your dancer!
Consent, Risk & Liability Terms
ACKNOWLEDGMENT AND ASSUMPTION OF RISK

I understand that participation in dance, movement, fitness, conditioning, flexibility training, yoga, camps, workshops, rehearsals, performances, games, crafts, and related Mandala Academy activities involves physical activity and inherent risks. These risks may include, but are not limited to, falls, collisions, muscle strains, sprains, overexertion, contact with other participants, and injuries involving floors, equipment, props, or performance spaces.

I understand that Mandala Academy takes reasonable safety precautions, but no physical or recreational activity can be made completely risk-free. I voluntarily choose to participate or, if signing as a parent or legal guardian, voluntarily authorize the participant named above to participate. I agree to disclose relevant medical conditions, allergies, injuries, restrictions, emergency medications, and requested accommodations before participation and to notify Mandala Academy if that information changes. The participant agrees to follow safety instructions and to notify an instructor if they experience pain, illness, dizziness, or another condition that may affect safe participation.

EMERGENCY MEDICAL AUTHORIZATION

If an illness, injury, or medical emergency occurs, I authorize Mandala Academy instructors or designated staff to provide reasonable basic first aid, contact emergency services, and seek emergency medical assistance when reasonably necessary. Every reasonable effort will be made to contact the participant’s parent/legal guardian or emergency contact. I understand that Mandala Academy staff are not medical providers and cannot diagnose or treat medical conditions beyond basic first aid. I accept financial responsibility for charges imposed by third-party medical providers or emergency services.

PARENT/GUARDIAN CONSENT AND ACKNOWLEDGMENT

If signing for a minor, I certify that I am the participant’s parent or legal guardian and have authority to give permission for the participant to take part in the activities described above. I acknowledge the identified risks, consent to the participant’s participation, and confirm that the information provided in this form is accurate to the best of my knowledge.

ADULT RELEASE OF LIABILITY

If I am the participant and age 18 or older, in consideration of being permitted to participate, I voluntarily assume the risks associated with the activities described above. To the fullest extent permitted by Kentucky law, I release and waive claims against Mandala Academy, its owner Jami Rankin, and their instructors, assistants, volunteers, and host facilities arising from or related to my participation, including claims based on ordinary negligence. This release does not apply to gross negligence, reckless conduct, or intentional misconduct. I understand that I am giving up certain legal rights by signing this release, and I confirm that I have had an opportunity to read and understand it before signing.
Optional Photo and Video Permission

Selecting No will not affect eligibility to participate. If Yes is selected, I authorize Mandala Academy to photograph or record the participant during programs, rehearsals, performances, and events and to use those images or recordings for its website, social media, printed promotional materials, and other marketing without compensation. Permission may be withdrawn prospectively by written notice, although materials already printed, published, or shared may not be retrievable.
Photo and Video Permission
Signer’s Electronic Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I confirm that I have read and understand the sections applicable to me or the participant. I understand that this form must be completed before participation, and I intend for my electronic signature to have the same effect as my handwritten signature.
Should be Empty:

Mandala Academy Participant Information & Liability Waiver

Signer Information (Parent/Guardian or Adult Participant)

Emergency Contact

Participant Information

Consent, Risk & Liability Terms

Optional Photo and Video Permission