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CenterStage Cheer and Dance LLC Registration & Waiver Form

CENTERSTAGE CHEER AND DANCE LLC. (C.C.D., LLC) ACKNOWLEDGMENT, AUTHORIZATION AND RELEASE FORM

In consideration for (athletes name) ________________________________________s participation in the activities provided by C.C.D., LLC, including but, not limited to all aspects of cheerleading, tumbling, trampoline, and dance training and/or competition, I am fully aware that any activity involving motion, height, or athletic activity creates the possibility of serious injury. I hereby release C.C.D., LLC, including its officers, shareholders, agents, and employees, from any liability to the above named athlete, of the person claiming through him/her, arising from injury to the person or property of the above named athlete occurring on the premises of C.C.D., LLC, including any event sponsored or sanctioned by C.C.D., LLC, and/or travel to and from such activities. This release includes but is not limited to any claims of negligence, dangerous condition, latent defect, premises liability, code violation, negligent security, failure to warn, vicarious liability, negligent hiring, negligent supervision, negligent maintenance, or improper/dangerous equipment; it is intended to be as broad as permissible under Florida Law. I am fully aware of the nature of the activities provided and the possibility of injuries arising from such activities. I further agree to hold harmless, indemnify and defend C.C.D., LLC, including its officers, shareholders, agents, and employees from any loss, liability, damage, or cost incurred by them due to the above named athlete on the premises or during any event sponsored or sanctioned by C.C.D., LLC. This release is intended to be binding upon the athlete his/her heirs, assignees, and successor in interest, and anyone claiming by or through him/her. In addition, I have read and understood the registration form and agree to all terms as stated above. I also attest that all information given is factual. I certify that the athlete is in good health and may participate in activities at C.C.D., LLC. In case of an emergency requiring medical treatment, the undersigned hereby authorizes C.C.D., LLC, to take the above named athlete to a qualified medical or hospital facility for care and treatment.

Athletes Name: Athletes Sinature:

Date:

Parent / Legal Guardians Name: Parent / Legal Guardians Signature: Date: 

Please select who will be entering the gym and/or participating in a CenterStage Cheer and Dance LLC event...
AdultMinor(s)
1 Minor2 Minors3 Minors4 Minors5 MinorsMore Minors6 Minors7 Minors8 Minors9 Minors10 Minors
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First Athlete Name

First Name*

Middle Name

Last Name*

Phone*
First Athlete Date of Birth*
First Athlete Signature*
Second Athlete Name

First Name*

Middle Name

Last Name*

Phone*
Second Athlete Date of Birth*
Third Athlete Name

First Name*

Middle Name

Last Name*

Phone*
Third Athlete Date of Birth*
Fourth Athlete Name

First Name*

Middle Name

Last Name*

Phone*
Fourth Athlete Date of Birth*
Fifth Athlete Name

First Name*

Middle Name

Last Name*

Phone*
Fifth Athlete Date of Birth*
Sixth Athlete Name

First Name*

Middle Name

Last Name*

Phone*
Sixth Athlete Date of Birth*
Seventh Athlete Name

First Name*

Middle Name

Last Name*

Phone*
Seventh Athlete Date of Birth*
Eighth Athlete Name

First Name*

Middle Name

Last Name*

Phone*
Eighth Athlete Date of Birth*
Ninth Athlete Name

First Name*

Middle Name

Last Name*

Phone*
Ninth Athlete Date of Birth*
Tenth Athlete Name

First Name*

Middle Name

Last Name*

Phone*
Tenth Athlete Date of Birth*
Athlete Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
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*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
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. All payments are non-refundable.


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