Waiver Form Required for Belly Class Participation at Moody Street Circus

Date: _____________________________

Participant’s name___________________________________________________________________________

Address_______________________________________City______________State___________Zip_________

Email ___________________________________________________

Home Phone (____)_______________________

Work phone (_____)_______________________

Cell phone (____) _________________________

Emergency Contact:

Name ___________________________________________ Phone # ___________________________

Address (if different from above)_______________________________________





Relationship ________________

Physician’s name ______________________________________ Phone # ________________________

Are there any medical conditions or special needs (consider pre-existing knee or back injuries, past operations, aches and pains, allergies, physical and mental health, behavior or emotional problems, etc) that we need to be aware of? (please write on the back of this sheet if necessary) Is there anything else you’d like us to keep in consideration?

How did you first hear about Moody Street Circus?

_______________________________________________________________________________________

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY

AND PARENTAL CONSENT AGREEMENT ("AGREEMENT")

IN CONSIDERATION of being permitted to participate in any way in the belly dance and circus arts activity ("Activity") I, for myself for personal representatives, assigns, heirs, and next of kin:

1. ACKNOWLEDGE, agree, and represent that I understand the nature of belly dance and circus arts activity and that I am qualified , in good health, and in proper physical condition to participate in such Activity. I further agree and warrant that if at any time I believe conditions to be unsafe, I will immediately discontinue further participation in the Activity. 
2. FULLY UNDERSTAND THAT: (a) AS WITH AN ATHLETIC ART FORM, BELLY DANCE MOVEMENTS INVOLVE RISKS AND DANGERS OF SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS, AND DEATH ("RISKS"); (b) these Risks and dangers may be caused by my own actions or inactions, the actions or inactions of others participating in the Activity, the condition in which the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c) there may be OTHER RISK AND SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a result of my participation or that of the minor in the Activity. 
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE Moody Street Circus, Melina of Daughters of Rhea, Cirque Passion, their respective administrators, directors, agents, officers, members, volunteers, and employees, other participants, any sponsors, advertisers, and, if applicable, owner and lessors of premises on which the Activity takes place, (each considered one of the "RELEASEES" herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON MY ACCOUNT CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE "RELEASEES" OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS AND I FURTHER AGREE that if, despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT I, or anyone on my behalf, makes a claim against any of the Releasees, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES from any litigation expenses, attorney fees, loss, liability, damage, or cost which may incur as the result of such claim.
4. I certify that I have adequate insurance to cover any injury or damage I or my child may cause or suffer while participating in belly dance related activities, or else I agree to bear the costs of such injury or damage myself.  I further certify that I am willing to assume the risk of any medical or physical condition I may have.
5. PHOTO CONSENT:  I agree that the Released Parties may use my or my child’s photograph in the routine promotion of its classes and activities on the Moody Street Circus website, and for other non-commercial applications.
6. PROFESSIONAL CODE:  I understand that belly dance and circus arts skills include physical activities which may cause injuries, and often require instructors to touch students as part of the learning process.  I understand that all instructors at Moody Street Circus are highly qualified and will use their professional discretion when assisting each student
7. By signing this document, I acknowledge that if anyone is hurt or property is damaged during my participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against the Released Parties on the basis of any claim from which I have released them herein.

I HAVE READ THIS AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND HAVE SIGNED IT FREELY AND WITHOUT INDUCEMENT OR ASSURANCE OF ANY NATURE AND INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.

Signature of Participant_________________________________________________

Print Name __________________________________________________________

Date_____________________________

PARENT’S OR GUARDIAN’S ADDITIONAL INDEMNIFICATION   (Must be completed for participants under the age of 18)

In consideration of ________________________________________ (Print Minor’s Name) (“Minor”) being permitted by the Released Parties to participate in its activities and to use its equipment and facilities, I further agree to indemnify and hold harmless the Released Parties from any and all Claims which are brought by, or on behalf of Minor, and which are in any way connected with such use or participation by Minor.

Parent or Guardian_____________________________________





Print Name ___________________________________________




Date___________

Circus Arts Registration & Waiver Form Required for Participation in Moody Street Circus Classes

Student’s name_______________________________ Gender F/M______ Age ______ DOB ____/_____/____

Entering grade in 2010-2011 school year__________School_____________________________________

Address_______________________________________City______________State___________Zip_________

Email _________________________________________________

Home Phone (____)_______________________

Parent’s name (if applicable)______________________________________


Work phone (_____)______________

Address (if different from above)____________________________________


Cell phone (____) ______________

Emergency Contact:

Name ___________________________________________ Phone # ___________________________

Address (if different from above)_______________________________________

Relationship ________________

Physician’s name ______________________________________ Phone # ________________________

Insurance Company ___________________________ Group number _______________

Member number______

Are there any medical conditions or special needs (consider allergies, physical and mental health, behavior or emotional problems, etc) that we need to be aware of? (please write on the back of this sheet if necessary)

PARTICIPANT AGREEMENT, RELEASE AND ASSUMPTION OF RISK

In consideration of the services of Moody Street Circus, Cirque Passion School of Circus Arts, Daughters of Rhea Belly Dance Company, their agents, owners, officers, sponsors, commissioners, trustees, affiliates, volunteers, participants, employees, and all other persons or entities acting in any capacity on their behalf (the “Released Parties”), I hereby agree to release, indemnify, and discharge the Released Parties, on behalf of myself, my spouse, my children, my parents, my heirs, assigns, personal representative and estate as follows:

I acknowledge that my or my child’s participation in a circus arts day camp, workshop, circus training or aerial apparatus class entails known and unanticipated risks that could result in physical and emotional injury, paralysis, death or damage to myself, to property, or to third parties.  I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity.

Without a certain degree of risk, circus students would not improve their skills, and the enjoyment of the activity would be diminished.  The risks include, among other things: Circus training exposes its participants to the usual risk of cuts and bruises.  Other more serious risks exist as well.  Participants can fall and sustain sprains and strains, and can suffer more serious injuries as well.  Traveling to and from shows, meets and exhibitions raises the possibility of any manner of transportation accidents.  In any event, if you or your child is injured, you or your child may require medical assistance, at your own expense.

Furthermore, the Release Parties employees have difficult jobs to perform.  They seek safety, but they are not infallible.  They might be unaware of a participant’s fitness or abilities.  They might misjudge the weather or other environmental conditions.  They may give incomplete warnings or instructions, and the equipment being used might malfunction.

I expressly agree and promise to accept and assume all the risks existing in this activity.  My participation in this activity is purely voluntary, and I elect to participate in spite of the risks.

I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless the Released Parties from any and all claims, demands, or causes of action, which are in any way connected with my participation in this activity or my use of the Released Parties’ equipment or facilities, including any such claims which allege negligent acts or omissions of the Released Parties.

Should the Released Parties or anyone acting on their behalf, be required to incur attorney’s fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.

I certify that I have adequate insurance to cover any injury or damage I or my child may cause or suffer while participating, or else I agree to bear the costs of such injury or damage myself.  I further certify that I am willing to assume the risk of any medical or physical condition I may have.

In the event that I file a lawsuit against the Released Parties, I agree to do so solely in the state of Massachusetts, and I further agree that the substantive law of that state shall apply in that action without regard to the conflict of law rules of that state.  I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.

PHOTO CONSENT:  I agree that the Released Parties may use my or my child’s photograph in the routine promotion of its classes and activities, and for other non-commercial applications.

PROFESSIONAL CODE:  I understand that circus skills include physical activities which may cause injuries, and often require instructors to touch students as part of the learning process.  I understand that all instructors at Cirque Passion’s Circus Arts School at Moody Street Circus are highly qualified and will use their professional discretion when assisting each student.

By signing this document, I acknowledge that if anyone is hurt or property is damaged during my participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against the Released Parties on the basis of any claim from which I have released them herein.

I have had sufficient opportunity to read this entire document. I have read and understood it, and I agree to be bound by its terms.

Signature of Participant_________________________________________________ Print Name _____________________________________

Address ______________________________________________________________________________________________________________

Phone ___________________________________________________ Date_____________________________

PARENT’S OR GUARDIAN’S ADDITIONAL INDEMNIFICATION   (Must be completed for participants under the age of 18)

In consideration of ________________________________________ (Print Minor’s Name) (“Minor”) being permitted by the Released Parties to participate in its activities and to use its equipment and facilities, I further agree to indemnify and hold harmless the Released Parties from any and all Claims which are brought by, or on behalf of Minor, and which are in any way connected with such use or participation by Minor.

Parent or Guardian_____________________________________Print Name __________________________________ Date___________