Intersession with Dance Exchange

Youth Intersession with Dance Exchange

Register your child and select your preferred payment option for the Breakthrough Intersession program at Dance Exchange
Participant Full Name

First NameLast Name
Participant Age
Parent/Guardian Name

First NameLast Name
Parent/Guardian Email
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
LIABILITY RELEASE: I acknowledge that I have voluntarily enrolled my child in this program and assume responsibility for all risks of injuries resulting from our participation in activities with Dance Exchange. I certify that my child is physically and mentally capable of participating in these activities. I hereby represent that I have informed Dance Exchange of any pertinent medical conditions that may affect participation in these activities, including but not limited to classes, rehearsals, performances, or related events. I voluntarily agree to release, discharge, and hold harmless Dance Exchange for any and all claims of liability which causes injury, whether based on allegations or not, in any way. Should emergency medical services become necessary for the undersigned participant, the expenses are the sole responsibility of myself and not that of Dance Exchange. I understand that this agreement is between myself and Dance Exchange, its owners, officers, board, agents, and employees and that it cannot be modified or changed in any way by the representatives or statements by Dance Exchange or by myself.
PHOTO / VIDEO MEDIA RELEASE: I hereby grant to Dance Exchange the irrevocable and unrestricted right to use and publish, alter, and copyright quoted material, photographs or video images of me or my child, including audio recordings, text / writings / drawings produced for Dance Exchange publications, electronic reproductions (website) and/or any other purpose and in any manner or medium an unlimited number of times in perpetuity for any lawful purpose. I hereby release the photographer / videographer / documenter and the Dance Exchange from all claims and liability relating to said media. I understand that the Dance Exchange will exercise extreme care in protecting the context of quoted material or image. I understand that I will not receive any monetary compensation for the permissions I am granting herein. I understand that I cannot withdraw this consent after I submit this form and that this consent and release is binding.
Select Your Registration Option
Select Your Registration Option
For scholarship / financial aid requests, please describe your financial need:
Please note that only a limited number of scholarships are available for this program.
Dance Exchange will send an Invoice to the Parent/Gaurdian email address above. Once you click the SUBMIT button below, you will be invoiced for the full amount, OR you will receive a notification regarding how much scholarship funding is available to you.
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Youth Intersession with Dance Exchange