Dancer’s Name *

First Name

Last Name

Brithday *

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DD

YYYY

Parent 1 *

First Name

Last Name

Best Contact Number *

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent 2

First Name

Last Name

Phone

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Address

If differs from Parent 1.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

*

RELEASE OF LIABILITY, WAIVER OF LIABILITY, ASSUMPTION OF FULL RESPONSIBILITY OF ALL RISKS OF BODILY INJURY OR DAMAGES: As a participant myself, and/or as a parent or legal guardian of the River Valley Dance Company dance student(s), I give my consent for her/him to participate in the programs at RVDco. I understand that participation in dance, tumbling, stretching and other related activities may result in injuries. These injuries may include muscle strains and tears, broken bones, and severe injuries such as permanent paralysis or even death. I am fully aware of the risks and, possibility of injury involved in these activities, and assume full responsibility for such risks. I understand that it is this dance studio's intent to provide for the safety and protection of me and/or my child or children, and in consideration for allowing myself and/or the above-named minor child(ren) to participate in activities with RVDco, I waive any and all rights or causes of action against Sam Budzinski and/or Staff at RVDco for any injuries suffered by my child(ren) and other damages suffered my child(ren), or myself, while under the supervision or control of RVDco and its employees, staff and independent contractors. This acknowledgment of risk and WAIVER OF LIABILITY has been read by me, understood completely and agreed to voluntarily. I am 18 years of age or older. This agreement will remain in effect until written revocation is received.

I give permission to allow RVDco to take and post pictures and/or videos of my dancer(s), at dance, performances or other RVDco events for use on the website, Facebook, Instagram, in brochures, etc. All pictures and videos taken by RVDco staff are property of River Valley Dance Company. If you do not allow pictures/videos of your child to be posted, please send an email indicating

I have read and understand that TUITION IS DUE BY THE 5TH OF EVERY MONTH. I have read and understand that there will be a $10.00 late fee added for every week tuition is late.