Release Form — Appalachian Rhythm

medical/physical fitness/injury release form

A. It is the desire of the undersigned student and parents that the student attend dance classes at Appalachian Rhythm Clogging & Dance.
B. It is the desire of Ashley Moseley and the instructors at Appalachian Rhythm to provide the student with the finest dance instruction available.
C. The student, parents and the dance instructors are aware that dance is a very stressful, demanding athletic art form and that injuries both of a minor and serious nature can and do occur. It is necessary for the student and the parents to realize that they are assuming a known risk of injury in pursuing instruction in dance.
D. It is the desire of both the student and the parents to release Appalachian Rhythm from any and all liability for damages and injuries received as the result of attending such dance instruction.
E. It is the desire of the student, parents and the dance instructors that the student maintain a physically fit and healthy lifestyle in efforts to promote the student in his/her dance education and training.

Does the dancer have any known allergies

NO

YES

If yes, please list:

Does the dancer have any conditions that we should be aware of?

NO

YES

If yes, please list:

I, the undersigned, parent/guardian, of said student, give my permission and authorization for any Appalachian Rhythm representative to arrange for and/or provide transportation to the nearest facility and treatment as indicated to be administered (if a parent or guardian or emergency contact number is unavailable). I also understand that an Appalachian Rhythm representative will notify me as soon as possible of this occurrence.

YES

NO

Parent or Guardian

First Name

Last Name

Phone

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Alternate Emergency Contact

First Name

Last Name

Phone

(###)

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Alternate Emergency Contact

First Name

Last Name

Phone

(###)

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