Waiver

Participant Info:

First Name:

Last Name:

Preferred Name:

Date of Birth:

Age:

Parent/Guardian #1 Info:

First Name:

Last Name:

Preferred Name:

Date of Birth:

Age:

Parent/Guardian #2 Info:

First Name:

Last Name:

Preferred Name:

Date of Birth:

Age:

Contact Info:

Email Address:

Phone Number:

Street Address:

City:

Postal Code:

Health Info:

Allergies (please specify):

Present Medical Conditions (ie asthma, heart murmur)

AB Health #:

Family Doctor Name:

Family Doctor Phone:

Additional Pick-up Authorization:

IN ADDITION TO THOSE LISTED ABOVE, THE FOLLOWING PEOPLE ARE AUTHORIZED TO PICK UP MY CHILD NO LATER THAN 4 PM ON WORKSHOP DAYS:

Name:

Relationship:

Phone:

Name:

Phone:

Relationship:

Agreements:

I agree that my child's allergies and medical issues will be known to all staff to ensure safety.

I agree

I agree to allow my child to be photographed while at the camp. The image may also be used for future promotions.

I agree

I agree to have my child taken outdoors with instructors while remaining on school property.

I agree

I agree to have my child perform in the final show if they agree to participate.

I agree

I agree to leave my child only for the established workshop hours.

I agree

I agree to abide by the rules of the circus camp program.

I agree

I agree to disclose all pertinant information regarding my child to camp staff.

I agree

Signature:

Today's date:

I freely and voluntarily assume any risk and hazards inherent in the attendance of my child or myself at Dream Dance Circus and participation in programs or activities organized by Dream Dance Circus. I waive any claim I may have against Dream Dance Circus, including any directors, officers, employees or agents associated with Dream Dance Circus, arising from my child’s attendance and participation in any program or activities. I agree in indemnity and save harmless Dream Dance Circus for any claim, including any claim for medical services arising from my child’s participation in any Dream Dance Circus program or activities.

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