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.
January 20, 2022
I have read this document and have been given the opportunity to ask questions.