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Personal Release of Liability Waiver.

Assumption of Risk, Release of Liability for Personal Injury, Medical Authorization

I, the participant, do hereby release Stephanie McKinley Chabloz, The Los Angeles Bellydance Academy (LABA), Mid City Arts Centerand its representatives from any and all liability or in any way related to my use of the facilities, equipment, or apparatus at The Los Angeles Bellydance Academy (LABA), its owners, operators, instructors, employees, agents, servants and affiliated center(s); and /or my participation in any class, program, competition or other event organized, run and/or sponsored by or held at The Los Angeles Bellydance Academy (LABA), hold harmless the said claims, demands, costs, expenses and compensation arising out of or in the course of or in any way related to any personal injury to me.

By signing this release, I acknowledge my understanding and acceptance of the following:

That dance can be an active sport, which requires strength, agility and concentration and that it is solely my responsibility to determine that I am in good health and good physical and mental condition before permitting myself to exercise, work out, receive instruction or perform.

In the event of an accident or emergency I would like to be taken to a hospital for medical treatment and I hold Stephanie McKinley Chabloz, The Los Angeles Bellydance Academy (LABA) and its representatives harmless in their execution of this action. Additionally, I hereby agree to individually provide for all possible future medical expenses, which may be incurred by me as a result of any injury, sustained while participating at or for the Los Angeles Bellydance Academy (LABA).

 

I grant to Los Angeles Bellydance Academy, its representatives and employees the right to take photographs and or video of me and my property in connection with the company. I authorize Los Angeles Bellydance Academy, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Los Angeles Bellydance Academy may use such images of me with or without my name and for any lawful purpose, including for example such purposes as publicity, advertising, and Web content.

December 4, 2020

I have read this document and have been given the opportunity to ask questions.

I Agree

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*
Check here if you wish to be updated on up on the latest events, and class scheduling from LABA.
A signed copy of this waiver will be sent to the email address you provide.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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