Toledo Ballet Summer Enrichment Camps Registration Form (Continued) Choose your preferred payment: -- Check (Please make payable to Toledo Ballet.) Visa/Master Card/Discover Credit Card #:-------------------- Name on Card: Expiration Date: -------------------- Complete registration form and return to: Toledo Ballet 500 I Monroe Street, Suite R20 Westfield Franklin Park Mall Toledo, OH 43623 (419) 471-0049 or www.toledoballet.net I .The undisclosed student or parent/guardian hereby consents to my or my daughter or sons participation in the classes. programs.rehearsals.and pcrformances(“Activi tics’) at the Toledo Ballet or contr.letcd theater space. In consideration of my chi ld’s participation in such Activities.in addition to the payment of any fcc.I do hereby waive.release and forever discharge the Toledo Ballet Association and its trustees.agents.employees.instn•ctors.and all others (“Relcasces’)Toledo Ballet from any and all responsibili tiesor l iability for in juriesor damages resulting from my or my child ‘s partici pation in any Activities. I do also release all of the Rclcasccs from any responsibili ty orliabili ty for any injury or damage to myself or my child.arising out of or connected with my or m y child’s participation in an y Activi ties with the Toledo Ballet. 2.Tuition is paid by each session and is nonrcftmdablc except if the student should permanen tly leave the geographicalarea.or if there isa permanent medical reason with a sisncd physician’s note. Should the student have a temporary medical excuse.a credit for a subsequent term will be applied to t heir account. 3.Furthermore.I agree to indemnify the Rclcasces and each of them from any loss.claim.damage.suit.costs. or expenses.including attorneys·fees and court costs.resulting from or arising out of any injury to any person or damage to property. caused by participation of Releasor in any activitiesat theToledo Ballet. 4.I further acknowledge that traini ng and performing dance is a potentiall y hazardous activity. I also understand that such Activities involve a risk of in jury an d even death and that I am voluntarily participating or vol untarily enrollin g my child i n these activities with knowledge of the dangers involved. I hereby agree to expressly assu me and accept full responsibility for the risks ofbodil y injury or death while Releasor participates in any Activities with the Toledo Ballet. 5.!understand that photographers arc often in vited toToledo Ballet events for publicity purposes.I agree to the usc of my or my child’s i mage or likeness in promotional materials in cluding.but not limited to. brochures.newspaper articles.books. and/or television in perpetuity. 6. I expressly agree that this release.waiver and indemnity agreement isintended to be as broad and inclusive as permitted by the lawsof the State of Ohio.and that if any portion of th is agreement is held invalid.it is agreed that the balance shall. notwithstanding.continue in full legal force and effect. 7. I further authorize the Toledo Ballet Association toseek medical attention for myself or my child.if in the judgment of the staff members it sh ould be necessary.In the event my ch ild should require medical attention and/or treatment during the course of any Acti vities and after a reasonable attempt I cannot be contacted for the purpose of consen tin g tosuch treatment in a tim ely man ner. I hereby give permission to any hospital.physician.and/or oth er appropriate h ealth care providerselected by the staff members to undertake any form of medical treatmen t considered necessary or appropriate by such provider in such event.
Doctor’s Name: __________________________________ PhoneNumber: __________________Major medical issues/allergies:________________ Date:___________________ Signature X: ______________________________________
Sleeping Beauty
Summer Enrichment Camps