Name_______________________________

Age:___________ Birthdate:______________

Email addresses:______________________,___________________________

Mailing Address:______________________________________

Cell Phone Numbers:_________________,___________________

Classes Enrolling In:____________________,____________________

Experience:___________​___________________________________

Hold Harmless Statement:

I certify that my child is in proper physical condition to take part in dance classes. I realize that there are certain risks possible in dance. I agree to assume the risk of all injuries or damage that may arise from my child's participation in Upbeat activities.

In consideration of the above, I hereby release and hold harmless Upbeat Dance Center, its employees, the Director, and the Landlord of Meetinghouse Plaza from and against any liability or claim for any loss of property, injury, misadventure, harm, cost, or damage sustained as a result of my child's participation at Upbeat Dance Center. 

I have read this release and understood its meaning. 

Signature:______________________________Date:______________

If you are aware of any medical conditions, learning disabilities, or limitations please state them here:____________________________________________________________________________________