Adult Student Release Form

Student Phone *

(###)

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Student Birthdate *

MM

DD

YYYY

New or returning student *

Returning Student (Updating Form on File)

New Student

Student Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name *

Primary Parent or Guardian for students under 18 years

First Name

Last Name

Emergency Contact Phone *

(###)

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1. *

I understand that dance is a physical art form and injury is inherent. Every effort has been made to keep the studio a safe and appropriate environment for learning and performing dance class. If an injury does occur, the student or student's parent/guardian (under 18) is responsible for medical expenses incurred and will not hold Schramel Conservatory of Dance liable.

Yes, I understand.

2. *

The Directors and Faculty are qualified to teach students at the appropriate level and have the right to advise a student if they feel the student is not ready for a certain level.

Yes, I understand.

3. *

I understand that the student may be touched in an appropriate manner by the teacher in order to achieve a certain position of the body as it pertains to the dance form. The student may also request the teacher does not touch for any corrections or demonstration of proper placement.

Yes, I understand.

4. *

I certify the student has no health issues which could impact or interfere with their ability to safely participate in dance class. If there is a health issue, I will notify the directors of the problem to clarify any potential limitations.

Yes, I understand.

Date *

MM

DD

YYYY