Ballet Class Registration (2022-2023 Season) Ballet Registration 2022-2023 PARENT / RESPONSIBLE PARTY:Name(s):(Required) First Last Address: Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Contact's email address:(Required) Enter Email Confirm Email Contact's mobile telephone number:(Required)DANCER INFORMATION & RELEASE:Select Ballet Class:(Required) Ages 3 & 4 - Leap 'N Learn Ballet ( $63.00/mo ) Ages 5 & 6 - Leap 'N Learn Ballet ( $68.00/mo ) Ages 7 to 11 - Beginning Ballet ( $68.00/mo ) Ages 12 & Up - Beginning/Intermediate Ballet( $68.00/mo ) Name of Child / Dancer:(Required) Dancer's Age:(Required) Date of Birth: MM slash DD slash YYYY Description of Dance Experience (if any):Participant Release:(Required) I agree I have read the Waiver and Release of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated below. This Waiver and Release shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.EMBODY BALLET LLC - PARTICIPANT RELEASE This is a legally binding release, waiver, indemnification of liability, and express assumption of risk. Please read carefully before agreeing. 1. Participant understands that Embody Ballet, LLC (“Embody Ballet”) fitness and dance classes (“activities”) involve physical exertion, may be strenuous, and that injuries may occur when participating in such activities. 2. Participant accepts and assumes the risks associated with Embody Ballet activities, including, but not limited to, small equipment malfunction or failure, overexertion, inability to perform suggested exercises or maneuvers, physical or mental conditions that impede the ability to properly perform suggested exercises or maneuvers, failure to properly use small equipment, and failure to follow instructions. Participant hereby freely and expressly assumes all risk of property damage, injury, and death associated with Embody Ballet activities. 3. Participant understands that it is his/her responsibility to consult with a physician prior to and regarding participation in dance and/or fitness. Participant represents and warrants that he/she has no physical or mental condition that would prevent full participation in Embody Ballet activities. Participant agrees to inform his/her instructor immediately of any physical or mental condition that would prevent his/her full participation in classes. Instructor may advise Participant of modifications for conditions, but Participant retains all risk of injury or death. 4. In consideration for participation in Embody Ballet activities, receiving instruction in a group, or workshops and using the equipment and facilities, Participant hereby agrees to release, hold harmless, and indemnify Embody Ballet and its owners, members, managers, partners, employees, independent contractors, directors, officers, agents, instructors, licensees and affiliates from any and all claims by or on behalf of Participant against Embody Ballet arising directly or indirectly out of Participant’s participation in Embody Ballet activities, use of any Embody Ballet equipment or facilities, and participation in any class, program, or workshop offered by Embody Ballet. This release includes claims and liabilities arising from any cause whatsoever, including, but not limited to, negligence on the part of Embody Ballet. This release is binding upon Participant, and Participant’s heirs, assigns, and legal representatives. 5. If signing on behalf of a minor Participant, Parent/Guardian accepts full responsibility for any medical expenses incurred due to the minor’s participation in Embody Ballet activities and agrees to release, hold harmless, and indemnify (including costs and attorney’s fees) Embody Ballet for any claims brought by or on behalf of the minor.