Liability Release Form

All participants and students must complete this form before participating in any classes or rehearsals with Hixon Dance. If participant is under age 18, a parent or guardian must also sign this form. Admission to class and/or rehearsal will not be granted if this form is not received prior to class and is not properly signed.
 
Waiver of Liability
I,___________________________________, recognize and understand the risks of physical injury inherent to dance and dance training and I fully assume those risks. I hereby release Hixon Dance, its employees, dance teachers, staff, volunteers, or board of directors from all liability for injuries sustained or illnesses contracted while attending or participating in any dance classes, rehearsals, workshops, or performances. I agree to indemnify, defend, and hold harmless Hixon Dance, its affiliate dance studios, event sponsors, employees and dance teachers for liabilities, costs and judgments arising from acts of omissions committed by me or my child which result in injury or damage to any person or property. Initials:_____________
 
Protection of Property
I understand and agree that it is my sole responsibility to safeguard my personal property while attending or participating in any classes, rehearsals, workshops, or performances. I hereby release Hixon Dance, its affiliate dance studios, event sponsors, employees and dance teachers from all liability for loss or damage to my personal property while attending or participating in classes, rehearsals, workshops, or performances. I also agree to abide by any rules, regulations and policies set forth by Hixon Dance. Initials:_____________
 
Medical Attention
In case of physical injury or medical emergency, I hereby authorize Hixon Dance to make necessary arrangements to transport myself or my child to a medical treatment facility as necessary. All such transportation and medical treatment will be at my sole cost and expense. In extreme emergency, or if my child is under 18 years of age, I understand that Hixon Dance will attempt to notify the person(s) I have named below as my emergency contact(s) of my condition and how to reach me. Initials:_____________
 
Photo/Video Release
Hixon Dance reserves the right to use photographs and videos taken during classes, workshops, performances, or other affiliated events for the purposes of instruction, advertising and promoting Hixon Dance and its programs. Students, or parents of students who are minors, who do not wish to comply with this policy must notify Hixon Dance prior to participation in class. Initials:______________
 
Acknowledgement of Waiver
In signing this Release, I acknowledge and represent that I have fully informed myself of the content of the waiver and hold harmless agreement by reading it before I sign it, and I understand that I sign this document as my own free act and deed; no oral representations, statements, or inducements, apart from the written statement, have been made. I further state that I am at least eighteen (18) years of age and am fully competent to sign this agreement; and that I execute this release for full, adequate, and complete consideration fully intending to be bound by the same. I further state that there are no health-related reasons or problems which preclude or restrict my or my child’s participation in this activity, and that I will pay any medical costs that may be attendant as a result of injury to me or my child. Initials:_____________
 
 
PLEASE PRINT CLEARLY
_____________________________________________________
Signature of Participant
 
________________
Date
 
_____________________________________________________
Printed Name of Participant
 
 
_____________________________________________________
Signature of Parent/Guardian (if under 18)
 
 
________________
Date
 
_____________________________________________________
Printed Name of Parent/Guardian
 
Emergency Contact Name:________________________________________________
 
Relationship to Participant:________________________________________________

Emergency Numbers:_____________________________________________________
 
Please list any medical conditions, injuries, allergies, etc. 
 

 

© 2017-2022,  HIXON DANCE 

director@hixondance.com
 

Columbus, OH
Worthington, OH

Hixon Dance is a 501(c)3 non-profit organization

380-222-4196  

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