Waiver

Logos_Final_BW_2_a.jpg

MOODY STREET CIRCUS BELLY DANCE AND CIRCUS ARTS STUDIO PARTICIPANT AGREEMENT, RELEASE & ASSUMPTION OF RISK

 

I (or if a I am a parent signing on behalf of a minor child), hereby agree to the following:

1. That I am participating in the Dance and Circus Arts or related Classes offered by Moody Street Circus during which I will receive training in Belly Dance and Ground & Aerial Circus Arts. I recognize that this requires physical exertion which may be strenuous and may cause physical injury and/or side effects from injury and I am fully aware of the risks and hazards involved.
2. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in any Dance or Circus Class or related Workshop (collectively referred to as “Activity”). I represent and warrant that I am physically fit and that I have no medical condition which would prevent my full participation in any Activity in which I participate. I understand that it is my responsibility to ascertain that I am capable of participating in any such Activity, and that I should continue to keep Moody Street Circus fully informed of any physical or other condition or disability which would prevent or limit my participation in any Activity.
3.In consideration of being permitted to participate in any Activity that I sign up for, I AGREE TO, AND, I ASSUME FULL RESPONSIBILITY FOR ALL RISKS, INJURIES OR DAMAGES, KNOWN OR UNKNOWN, WHICH I MIGHT INCUR AS A RESULT OF PARTICIPATING IN ANY SUCH ACTIVITY.
4. In consideration of being permitted to participate in any Activity that I sign up for, I hereby fully and forever release and hold harmless Moody Street Circus, its employees, owners, and agents (collectively called the “Releasees”) from and against any and all liability to me, my heirs executors, personal representatives, administrators and/or assigns, for any and all claims, demands, causes of action, losses and damages of any kind whatsoever on account of any injury including loss, injury, death or damage to my person and/or any property or to any other person and/or their property, caused or alleged to be caused by any action or inaction of any of the Releasees. I hereby waive any right to sue any of the Releasees for any injuries or damages I may incur whether known or unknown resulting from my participation in any Activity.
5. I understand and agree this document is to be binding on myself, my heirs, personal representatives,executors, administrators and assigns.
6. I AGREE TO DISCUSS ANY HEALTH RESTRICTIONS, QUESTIONS OR CONCERNS WITH THE INSTRUCTOR PRIOR TO ANY CLASS, PROGRAM OR WORKSHOP IN WHICH I AM
ENROLLED.
7. 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 or circus 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.
8. PROFESSIONAL CODE: I understand that belly dance and circus arts skills include physical activities which may cause injuries, and often require instructors to physically assist students as part of the learning and spotting process. I understand that all instructors at Moody Street Circus are highly qualified and will use their professional discretion when assisting each student.

I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above.

 
Student Name (or Parent's Name if signing for a minor)
Student Name (or Parent's Name if signing for a minor)
Cell Phone Number
Cell Phone Number
Emergency Contact Name
Emergency Contact Name
Emergency Contact Number
Emergency Contact Number
Minor 1 Student Name
Minor 1 Student Name
Minor 2 Student Name
Minor 2 Student Name