Trial Class Form

Parent or Guardian Name *

First Name

Last Name

Phone Number *

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Secondary Emergency Contact Name

First Name

Last Name

Phone Number

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Student Name *

First Name

Last Name

Student Date of Birth *

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DD

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Date *

Please select the date of your trial class:

MM

DD

YYYY

By checking the box below, I agree to the following Waiver of Liability for the Druid Hills Dance Center. By attending class at the Druid Hills Dance Center, I agree to the following. As a Participant in any program or class associated in any way with the Druid Hills Dance Center I acknowledge and recognize that there are certain inherent risks of physical injury, AND I HEREBY AGREE TO ASSUME THE FULL RISK of injury, including death, damages or other loss that I or my minor child may sustain as a result of participation in any activities connected or associated with such programs or classes. I FURTHER AGREE TO WAIVE AND RELINQUISH ALL CLAIMS I or my minor child may have as a result of participating in any programs or classes against Druid Hills Dance Center, and its owners, agents, servants, representatives, employees, independent contractors, officers, managers, successors or assigns. I FURTHER AGREE TO INDEMNIFY AND HOLD HARMLESS and defend Druid Hills Dance Center, and its owners, agents, servants, representatives, employees, independent contractors, officers, managers, successors or assigns, from my claims resulting from injury, including death, damages or other loss that I or my minor child may sustain as a result of participation in any activities connected or associated with such programs or classes. I HAVE READ AND FULLY UNDERSTAND THE ABOVE WAIVER AND RELEASE OF ALL CLAIMS. *

I agree to the Druid Hills Dance Center Waiver of Liability

By checking the box below, I agree to the following medical emergency authorization. The undersigned gives permission to Druid Hills Dance Center, its owners and operators to seek medical treatment for the participant in the event they are not able to reach a parent or guardian. I hereby declare any physical/mental problems, restrictions, or condition and/or declare the participant to be in good physical and mental health. I authorize all medical treatment and procedures as may be performed or prescribed by the emergency contact physician I have provided and/or the attending physician and paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian nor emergency contact persons can be reached in the case of a medical emergency. *

I agree to the Druid Hills Dance Center Medical Authorization

By checking the box below, I acknowledge that the Druid Hills Dance Center may use photos and videos taken during classes and performances for marketing purposes and promotional use. I understand that my student attending dance classes may be visible in any photo or videos used, and consent to their use by the Druid Hills Dance Center. *

I agree to the Druid Hills Dance Center Photo Waiver

By checking the box below, I understand and agree to the following conditions of attending class at the Druid Hills Dance Center: • No person (dancer, faculty, or staff) diagnosed with COVID-19, exhibiting symptoms of COVID-19, or having contact with a person that has or is suspected to have COVID-19 within the past fourteen (14) days will be allowed to attend classes at the Druid Hills Dance Center. • Temperatures of all persons (dancers, faculty, and staff) will be taken upon arrival with a touchless thermometer. Any person exhibiting a temperature greater than 100.4 degrees Fahrenheit, cough, shortness of breath, difficulty breathing, other respiratory symptoms, or at least two of the following symptoms: chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell will not be allowed to attend classes at the Druid Hills Dance Center. • Any person (dancer, faculty, or staff member) exhibiting a temperature greater than 100.4 degrees Fahrenheit, cough, shortness of breath, difficulty breathing, other respiratory symptoms, or at least two of the following symptoms: chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell will be separated from the group immediately and must leave the Druid Hills Dance Center as soon as practicable. • Any person (dancer, faculty, or staff member) that has stayed home sick or been prevented from attending DHDC classes due to signs of illness, or been sent home from DHDC due to signs of illness shall not be permitted back to class until they have either had a negative COVID-19 test or have been fever and fever mediation free for seventy-two (72) hours, other symptoms have improved, and at least ten (10) days have passed since symptoms first appeared. • All persons entering the Druid Hills Dance Center will adhere to the signage, social distancing markers, and safety rules given by instructors while at the Druid Hills Dance Center. *

I understand and agree to the above safety and healthy requirements regarding COVID-19