Pip Arts - Registration & Liability Form

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REGISTRATION & LIABILITY FORM

Positive Image Performing Arts
REGISTRATION FORM
PLEASE RETURN THIS FORM, REGISTRATION FEE & TUITION.

***NOTE: Tuition is due upon registering this dance student. All tuition and registration fee are 100% non-refundable. Classes fill quickly and we are
forced to turn away many potential students.

Student's Name

Age

Class Day(s) and Time(s)

Mother's Name

Mother’s Cell Phone

Mother’s Place of Business

Work Phone

Father's Name

Father’s Cell Phone

Father’s Place of Business

Work Phone

Email

Address

City

Zip

Home Phone

Date

Birthday

School

Grade in School

Information P.I.P.A should know about the student (medical, etc.)

How did you hear about P.I.P.A?

If student is transferring from another dance studio, please list studio and performance background.

Tuition Per Month tuition + registration fee (For office use only)

I am enrolling for POSITIVE IMAGE PERFORMING ARTS’ session. I understand that tuition is based on an
average of four classes per month, and I am responsible for payment of this tuition (by the first of the month), regardless of any
absences. To cancel this agreement, I understand that a written notification is required prior to the month of withdrawal. If this student decides to withdrawal, I understand that the June tuition payment and registration fee are non-refundable. I also authorize Positive Image Performing Arts to photograph and video my child, understanding that videos and pictures maybe used in advertisements, news stories and various other media outlets.

Signature

Date

POSITIVE IMAGE PERFORMING ARTS LIABILITY RELEASE FORM

This Document must be signed by the student or, if under 18 years of age, by his or her parent or legal guardian, prior to participating in any activity with POSITIVE IMAGE PERFORMING ARTS. Since dance and gymnastics is an inherently physical activity, injuries may occur. Each student may decline to participate in any activity which he or she deems to be harmful or painful, and must inform the instructor of any physical limitations, which may prevent full participation in class. By signing this document below, you (each member or student, or student's parent or legal guardian) agree to follow all written and oral policies, rules, and instructions that govern the operation of POSITIVE IMAGE PERFORMING ARTS. You affirm that you have reviewed and understand POSITIVE IMAGE PERFORMING ARTS’ policies and rules, and understand that any of these may be changed or amended at any times without prior notice. You understand that POSITIVE IMAGE PERFORMING ARTS has a "No Refund" policy, and that following your first class at POSITIVE IMAGE PERFORMING ARTS, your tuition will be non-refundable. You agree that if you engage in any form of dance, physical exercise, or other activity at POSITIVE IMAGE PERFORMING ARTS, you do so at your own risk. This includes, without limitation, your use of the main studio, any of the adjacent rooms, studios, offices, and sidewalk, any equipment, costumes, or stage props, and your participation in any activity, class program, or instruction. You agree that you are voluntarily participating in these activities and using these facilities and premises and assume all risk of injury, illness, damage, or loss to you or your property that might occur, including without limitation, any loss of theft of any personal property. You agree on behalf of yourself (and your personal representatives, heirs, executors, administrators, agents, and assigns) from any and all claims or causes of action (known and unknown) arising out of our negligence. This waiver and release of liability includes, without limitation, injuries which may occur as a result of:

your use of any equipment or facilities which may malfunction or break,

our improper maintenance of any equipment or facilities,

our negligent instruction or supervision, and

slipping/falling while at POSITIVE IMAGE PERFORMING ARTS or on the premis.

You acknowledge that you have carefully read this waiver and release and fully understand that it is a release of liability. You are waiving any right that you may have to bring a legal action to assert a claim against us for our negligence.
By signing below, you acknowledge and agree that all dancing and other exercises, or any other uses of POSITIVE IMAGE PERFORMING ARTS, are undertaken by you at your sole risk, and that POSITIVE IMAGE PERFORMING ARTS shall not be liable for any claims for injuries or damages whatsoever to your person or property, or of your guests, arising out of or connected with any use of POSITIVE IMAGE PERFORMING ARTS. You further agree to indemnify and hold POSITIVE IMAGE PERFORMING ARTS and its employees or other agents harmless from all claims by or liability to you or your guests. The sole exception shall be for those claims arising out of POSITIVE IMAGE PERFORMING ARTS knowing and intentional failure to correct a dangerous situation brought to its attention. This disclaimer is intended to provide a comprehensive release of liability, but it is not intended to assert any claims or defenses prohibited by law.

Student

Signature		Date

Parent/Guardian

Signature		Date

POSITIVE IMAGE PERFORMING ARTS

EMERGENCY INFORMATION CONTACT INFORMATION
In case of an emergency…

	First Person of Contact		Second Person of Contact

Name

Home Phone No

Cell Phone No

Relationship

Please list any Health and/or allergies concerns In case of emergency, if parent(s) cannot be contacted I hereby authorize:

POSITIVE IMAGE PERFORMING ARTS to act on my behalf in the interest (child’s name). If parent(s) or third party cannot be contacted, I authorize POSITIVE IMAGE PERFORMING ARTS authorities to act on my behalf in the interest of this child.

Parent / or Guardian’s Name

Parent / or Guardian’s Signature