Full of Grace Dance Instruction & Fitness Center
Emergency Medical Release & Liability Waiver
Participant’s Name ________________________________________________ Birthdate ___________________
Address ____________________________________________________________________
Number of years at Full of Grace __________________________________________________________________
E-mail address ___________________________________________________________________
Would you like to receive email updates/announcements (for example: closings, schedule updates, etc..) from Full of Grace
Dance Instruction & Fitness Center? ___ YES ___ NO
Is it OK to put a picture of your child on our website (on the internet)? ___ YES ___ NO
Emergency Information
Parent/Guardian Name ___________________________________________________________________
Home Phone Number ___________________________________________________________________
Cell Phone Number ___________________________________________________________________
Medical/Hospital Insurance Carrier _______________________________________________________________
Policy Holder’s Name __________________________________________________________________
Policy Number __________________________________________________________________
The Authorization for Emergency Medical Treatment must be completed before any classes may be started.
I, the undersigned (if participant is 18 years of age or older) or parent/guardian of the above listed minor acknowledge and fully understand that the participant will be engaging in activities that involve risk of serious injury, disability, or death. I accept personal responsibility for such injuries and release Full of Grace Dance Instruction and Fitness Center, it’s owner, agents, and volunteers from any and all liability. I, hereby, give my permission to Full of Grace Dance Instruction and Fitness Center, it’s owner, agents, and volunteers to seek emergency medical attention for the participant until I can be reached and agree to full financial responsibility for the cost of such treatment. I have read the above waiver/release and understand that I have given up the substantial rights in signing this release and sign below voluntarily.
Parent/Guardian Signature ____________________________________________________ Date _________
Participants Signature (if 18 or older) ____________________________________________ Date ____________
ATTACH A COPY OF YOUR INSURANCE CARD, FRONT AND BACK, TO EXPEDITE MEDICAL TREATMENT.
Emergency Medical Release & Liability Waiver
Participant’s Name ________________________________________________ Birthdate ___________________
Address ____________________________________________________________________
Number of years at Full of Grace __________________________________________________________________
E-mail address ___________________________________________________________________
Would you like to receive email updates/announcements (for example: closings, schedule updates, etc..) from Full of Grace
Dance Instruction & Fitness Center? ___ YES ___ NO
Is it OK to put a picture of your child on our website (on the internet)? ___ YES ___ NO
Emergency Information
Parent/Guardian Name ___________________________________________________________________
Home Phone Number ___________________________________________________________________
Cell Phone Number ___________________________________________________________________
Medical/Hospital Insurance Carrier _______________________________________________________________
Policy Holder’s Name __________________________________________________________________
Policy Number __________________________________________________________________
The Authorization for Emergency Medical Treatment must be completed before any classes may be started.
I, the undersigned (if participant is 18 years of age or older) or parent/guardian of the above listed minor acknowledge and fully understand that the participant will be engaging in activities that involve risk of serious injury, disability, or death. I accept personal responsibility for such injuries and release Full of Grace Dance Instruction and Fitness Center, it’s owner, agents, and volunteers from any and all liability. I, hereby, give my permission to Full of Grace Dance Instruction and Fitness Center, it’s owner, agents, and volunteers to seek emergency medical attention for the participant until I can be reached and agree to full financial responsibility for the cost of such treatment. I have read the above waiver/release and understand that I have given up the substantial rights in signing this release and sign below voluntarily.
Parent/Guardian Signature ____________________________________________________ Date _________
Participants Signature (if 18 or older) ____________________________________________ Date ____________
ATTACH A COPY OF YOUR INSURANCE CARD, FRONT AND BACK, TO EXPEDITE MEDICAL TREATMENT.