Summer 2025

Dancer's Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Parent/Guardian's Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home/Cell Phone *

(###)

###

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Home/Cell Phone #2 *

(###)

###

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Emergency Contact Phone *

(###)

###

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Please check the classes you would like to enroll in *

8/11 to 8/15 10:00a-12:00p 3-5yrs Beach Party Madison

8/11 to 8/15 9:00a to 12:00p 6-9 yrs Oh La La Aloha! Magen

7/31, 8/7, 8/14 5:00 to 7:00p 10+yrs Jazz & Lyrical Magen

DROP IN CLASS- 8/5 7:45 to 8:45 Adult Session: Jazz Emily

DROP IN CLASS- 8/12- 7:45 to 8:45 Adult Session: Lyrical/Contemporary Emily

Tuition & Late Fees *

- Tuition will be billed at the end of June. - There is a $35 non-refundable registration fee. - There is a $25 service fee for a returned payment. - There is a $25 late fee for past due tuition -If the tuition is not paid by the due date, your dancer will be withdrawn from the class or camp that was selected.

I've read the above and agree

Withdrawal *

-Class withdrawal requires a 30-day written notification or you are responsible for full tuition for the summer program you registered for.

I've read the above and agree

Photo Release (Please select ONE) *

I hereby grant and authorize Melrose Dance Academy the right to take, edit, alter, copy and make use of any and all pictures or videos taken of my dancer to be used in and/or for promotional materials including, but not limited to, newsletters, flyers, posters, brochures, letters, annual reports, and social networking sites for business use only. This is done without payment or any other consideration. This authorization shall continue indefinitely unless parent/guardian revoke in writing. I understand and agree that these materials shall become the property of Melrose Dance Academy and/or other facility that I represent, and will not be returned.

I DO NOT consent to the above Photo Release agreement and I do not want my dancer’s picture used for promotional materials, including, but not limited to, newsletters, flyers, posters, brochures, letters, annual reports, and social networking sites for business use only. Any photographs or digital images in which the subjects cannot be identified by the naked eye (i.e. wide shots of the stage containing the entire cast of the Recital) will be published at the discretion of Melrose Dance Academy.

Assumption of Risk *

In consideration of being permitted to participate in activities organized or facilitated by Melrose Dance Academy, I, acknowledge and agree to the following: -I understand and acknowledge that participating in dance activities involves inherent risks, including but not limited to the risk of injury, illness, or accidents, which may result from my own actions, the actions of others, or the conditions of the premises. -I voluntarily assume all risks associated with participating in Melrose Dance Academy activities, including but not limited to the risk of bodily injury, illness, or property damage, and I hereby release and discharge Melrose Dance Academy, its directors, employees, agents, and representatives from any and all liability for any injury, illness, or accident that may occur during my participation in Melrose Dance Academy activities. -I understand that Melrose Dance Academy does not provide medical insurance coverage for participants, and I agree to be solely responsible for any medical expenses incurred as a result of any injury, illness, or accident that may occur during my participation in Melrose Dance Academy activities. -I agree to indemnify and hold harmless Melrose Dance Academy, its directors, employees, agents, and representatives from any and all claims, liabilities, damages, losses, or expenses, including attorney fees, arising out of or related to my participation in Melrose Dance Academy activities.

I acknowledge that I have carefully read and fully understand the terms of this assumption of risk agreement, and I voluntarily agree to assume all risks associated with participating in Melrose Dance Academy activities.

Release of Liability

In consideration of being allowed to participate in activities organized or facilitated by Melrose Dance Academy, I, acknowledge and agree to the following: -I understand that participating in dance activities involves inherent risks, including but not limited to the risk of injury, illness, or accidents, and I voluntarily assume all such risks. -I hereby release, discharge, and hold harmless Melrose Dance Academy, its directors, employees, agents, and representatives from any and all liability, claims, demands, actions, or causes of action arising out of or related to any injury, illness, or accident that may occur during my participation in Melrose Dance Academy activities. -I understand that Melrose Dance Academy does not provide medical insurance coverage for participants, and I agree to be solely responsible for any medical expenses incurred as a result of any injury, illness, or accident that may occur during my participation in Melrose Dance Academy activities. -I agree to indemnify and hold harmless Melrose Dance Academy, its directors, employees, agents, and representatives from any and all claims, liabilities, damages, losses, or expenses, including attorney fees, arising out of or related to my participation in Melrose Dance Academy activities. -I understand that this release of liability is a legally binding contract and that I am giving up certain legal rights by signing it.

I acknowledge that I have read and understand the terms of this release of liability policy, and I voluntarily agree to be bound by its terms.

Medical Release *

In the event you are unable to reach me, in the case of accident or injury, I give my permission for treatment as deemed necessary by Melrose Dance Academy staff or emergency personnel. I also release Melrose Dance Academy and staff of liability in case of injury or accident.

I've read the above and agree

Date *

MM

DD

YYYY