Pure Ballet

Once accepted into the program, all participants will be required to sign the following form: 

Pure Ballet

Release & Waiver of Claims

Waiver of Liability and Hold Harmless Agreement

1. In the consideration of Pure Ballet providing the opportunity for and permitting the undersigned (Participant) to participate and take part in Pure Ballet and its related activities,

July 1, 2009 to June 30, 2010 the undersigned Participant and Parent of the Participant, do hereby release, remise and forever discharge, indemnify and agree to HOLD HARMLESS WAIVE, DISCHARGE, and COVENANT NOT TO SUE Pure Ballet, its officers, employees, faculty, instructors, servants, agents and assigns, hereinafter referred to as RELEASEES, from any claim, demand or cause of action whether now in existence, or hereafter arising for any loss of personal property, injury to the Participant or for the death of the Participant, arising out of resulting from, caused by or contributed to in whole or in any part by any action or failure to act, negligence, breach of contract, or other misconduct on the part of Pure Ballet, its officers, faculty, agents, servants, employees, (RELEASEES) any other Participant in said studio/program, any participating parent and/or any one or more of any thereof.

2. We recognize and acknowledge that certain risks of harm are or may be inherent in the various activities contemplated herein and that Pure Ballet nor Royce or Sarah Walston cannot control all of these risks. We are aware that ballet training and the gymnastic exercises associated with it place unusual stress on the body and carry with them the risk of physical injury. I / We assume the risks involved. I / We also understand that dance instruction involves kinetic correction that may include physically touching the student (Participant) as part of the regular class work and/or rehearsal. I / We assume the risk and agree that Pure Ballet faculty have permission to engage in appropriate kinetic correction of the body for technical corrective purposes as part of regular class work and rehearsal.

3. It is my/our express intent that this Release and Hold Harmless Agreement shall bind the members of my/our family if I am alive, and my heirs, assigns and personal representative, if I am not alive. It shall be deemed as a RELEASE, WAIVER, DISCHARGE, AND COVENANT NOT TO SUE the above named RELEASEES. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of Texas.

4. I UNDERSTAND THAT PURE BALLET WILL NOT BE RESPONSIBLE FOR ANY MEDICAL COSTS ASSOCIATED WITH ANY INJURY THAT I OR MY CHILD MAY SUSTAIN. 

5. I / We also understand that I / we should and am / are urged by RELEASSEES to obtain health and accident insurance to cover any personal injury to me / my child (Participant), which may be sustained.

6. I / We agree that I or my child (Participant) will adhere to the Rules and Regulations promulgated by Pure Ballet and obey all laws of the State of Texas while participating in this activity.

IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT I / We have read the foregoing Waiver of Liability and Hold Harmless Agreement, understand it and sign it voluntarily as my / I own free act and deed; no oral representations, statements or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent or, if I am under eighteen (18) years of age, my parent or legal guardian’s approval and signature has been obtained; and I / we execute this Release for full, adequate, and complete consideration fully intending to be bound by the same. 

IN WITNESS WHEREOF, I have hereunto set my hand on this _______ of _______, 20_____

Day Month Year

Student Name: _________________________________________________________________

Please Print

If 18 years of age or over: Yes __________ No __________

 

Participant Signature: _________________________________________ Date: _____________

 

Participant Printed Name: ________________________________________________________

 

Participant Address: _____________________________________________________________

 

Participant Phone Number: _______________________________________________________

 

Cell Phone Number(s): __________________________________________________________

 

Email Address: _________________________________________________________________

EMERGENCY INFORMATION Person(s) to be contacted in case of emergency:

 

Name: ___________________________________________ Relationship: ________________ 

Phone Numbers:

 

Home: ___________________________________ Cell: ________________________________

Work: ___________________________________ Other: _______________________________

Email Address: ________________________________________________________________

EMERGENCY INFORMATION (Con’t)

Name of Insurance Company: ____________________________________________________

 

Health Insurance Group Number: _________________________________________________

 

Policy Number: ________________________________________________________________

 

Address: _____________________________________________________________________

 

City: _______________________________________ State: ___________ Zip:_____________

 

Insurance Company Telephone Number: ___________________________________________

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 If I am under the age of eighteen, I have read, understood, and discussed with my parent or guardian identified below, and we hereby accept the terms and conditions stated in this

WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT

 

______________________________________ ____________________________________

Participant Signature Age Parent / Guardian Signature

 

______________________________________ ____________________________________

Printed Name Printed Name

 

______________________________________ ____________________________________

Address Address

 

______________________________________ ____________________________________

City / State / Zip City / State / Zip

 

______________________________________ ____________________________________

Date