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IMAGE DANCING SUMMER CAMP 2018 REGISTRATION (INDIVIDUAL OR FAMILY)Please fill out below as applicable. Answer "Same" for duplicate addresses, etc; If not applicable, please note "NA."SECTION 1 Personal Info (For each family, list student names)A. Parent/Guardian (of under-18 student) B. Student 1 D.O.B. Student 2 D.O.B. Student 3 D.O.B. Student 4 D.O.B. Phone Phone Phone Phone C. Mailing Address (with City, Zip) D. Best Phone Contact [ ] Phone's user Text?Y N E. Email User name Other Email User name F. Emergency Contact (not A) Phone Relation to student SECTION 2 Medical Release (All Students: ALL information is required)A. Does student(s) have allergies, physical/mental health conditions, or restrictions relevant to dance instruction?If yes, please describe: B. Doctor Phone Insurance C. Release of Liability (All Parents/Adult Students: Read & Sign)I ?understand ?and ?voluntarily ?agree ?to ?assume ?all ?risks ?and ?responsibility ?for ?any ?injury ?or ?accident, ?which ?might ?occur ?to ?me ?or ?my ?child ?during ?any ?of ?Image ?Dancing’s ?dance ?camps. ?I ?also ?exempt, ?release, ?and ?indemnify ?Image ?Dancing, ?its ?owners, ?volunteers, ?employees, ?guest ?artists, ?and/or ?students ?from ?any ?and ?all ?liability ?claims, ?demands, ?or ?causes ?of ?action ?whatsoever ?from ?any ?damage, ?loss, ?injury, ?or ?death ?to ?me, ?my ?children, ?or ?property ?which ?may ?arise ?out ?of ?or ?in ?connection ?with ?participation ?in ?any ?classes ?or ?activities ?conducted ?by ?Image ?Dancing. ?I ?further ?hereby ?voluntarily ?agree ?to ?waive ?my ?rights ?and ?that ?of ?my ?heirs ?and ?assigns ?to ?hold ?Image ?Dancing, ?its ?owners, ?volunteers, ?employees, ?guest ?artists, ?and/or ?students ?liable ?for ?such ?damage, ?loss, ?injury, ?or ?death. ?I ?understand ?that ?I ?should ?be ?aware ?of ?my ?physical ?limitations ?and ?agree ?not ?to ?exceed ?them. ?If ?I ?am ?signing ?this ?waiver ?for ?my ?children, ?I ?certify ?that ?I ?am ?the ?parent ?or ?legal ?guardian ?and ?have ?the ?right ?to ?waive ?these ?rights. ?Permission ?is ?granted ?to ?Image ?Dancing ?to ?seek ?required ?treatment ?for ?myself ?and/or ?my ?child ?in ?the ?event ?of ?emergency. ?Permission ?is ?granted ?to ?Image ?Dancing ?to ?use ?photographs ?of ?students ?for ?advertising, ?website, ?promotional ?materials, ?Facebook ?updates, ?etc. ?I ?have ?read, ?understood ?and ?agree ?to ?be ?bound ?by ?the ?above ?statements ?(please ?print ?your ?name, ?sign ?& ?date):Student or Parent Signature: Date Print Student or Parent Name Please Indicate Camp Session and Camp Name, etc.June/July Camp Camp Name #Dancers Who? (If more than 1 per family) ................
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