Dancer's Name *

First Name

Last Name

Dancer's Birthday *

MM

DD

YYYY

Parent/Guardian's Name *

First Name

Last Name

Primary Phone *

(###)

###

####

If you leave for the summer, When do you return?

*Only if applicable

MM

DD

YYYY

Emergency Contact

First Name

Last Name

Emergency Phone

(###)

###

####

Parental / Guardian Waiver *

I hereby release and agree to indemnify and hold harmless: Roman Lion LLC., all Roman Dance Company staff, instructors and personnel, and The Movement Complex from any liability and against any and all claims resulting from participation in this program, with my knowledge that by participating in this activity my child assumes risk of injury. I also hereby give permission to Roman Dance Company to use and display any photographs and videos taken of my child, which may be forwarded to newspapers and other publications in which the photograph would be associated with Roman Dance Company. I acknowledge that I have read Roman Dance Company's Policies and agree that I / my Dancer will abide by the rules set forth therein.

I Agree to Liability Terms and Conditions

I Agree to Policies & Procedures