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Caroline Calouche & Co. & Charlotte Cirque & Dance Center Waiver

I agree that Caroline Calouche & Co. / Charlotte Cirque & Dance Center its owners, officers, directors, employees, successors and agents shall not be liable for any harm my child may come to while on the premises of any educational programming, or for damage to their property. I hereby release, indemnify, and discharge Caroline Calouche & Co. / Charlotte Cirque & Dance Center on behalf of myself and/or my children, from any and all claims, demands, or causes of action, which are in anyway connected with my participation in this activity or my use of their equipment or facilities (except for gross negligence or willful misconduct).

I Agree

I assume any and all risk of injury (serious or otherwise) for me or my child. I further agree that if someone else is harmed through my child’s actions and blames the gym/venue, its owners, or its employees, for his harm, I will indemnify, defend, and old harmless the gym/venue, its owners, or its employees.

I Agree

I agree to release, hold harmless, and indemnify Caroline Calouche & Co. / Charlotte Cirque & Dance Center its owners and its employees from any and all harm. Further, I agree that if any lawsuit is filed against the Caroline Calouche & Co. / Charlotte Cirque & Dance Center its owners, or its employees, on account of my injuries, my child’s injuries or my child’s injuries to another on account of my child’s actions, I will defend, indemnify, and hold harmless Caroline Calouche & Co. / Charlotte Cirque & Dance Center its owners and its employees.

I Agree

Further, Caroline Calouche & Co. / Charlotte Cirque & Dance Center shall not be liable for any harm I or my child may come to, or any property loss that I or my child may incur, anywhere while using techniques learned in the studio and on location for an event, even though that harm may result from the participant’s negligence. I hereby release Caroline Calouche & Co. / Charlotte Cirque & Dance Center from any and all liability (except for gross negligence and / or willful misconduct) for such harm also.

I Agree

I or my child have read the safety rules of Caroline Calouche & Co. / Charlotte Cirque & Dance Center and agree to abide by them. I or my child is in good health and has no physical or mental limitations that would preclude them from careful and reasonably safe use of the gym/venue.

I Agree

In consideration of being permitted to participate in aerial dance activities including but not limited to Rope and Harness, Fabric and Trapeze (hereafter known as Aerial Dance Activities) at and/or under the auspices of Caroline Calouche & Co. / Charlotte Cirque & Dance Center, I do acknowledge, appreciate and agree that:

**The risk of injury resulting from Aerial Dance Activities is significant. The risk includes but is not limited to all manner of injury resulting from my falling during Aerial Dance Activities and hitting the floor, wall faces, people, rope, fabric, and fixtures – whether permanently or temporarily in place. This risk also includes, but is not limited to, rope/fabric abrasion, rope/fabric entanglement and burn, injuries resulting from falling and dropped items.

I Agree

I do knowingly and freely assume all such risks both known and unknown, and I do knowingly and freely assume all responsibility for my participation in dance and cirque activities at and/or under the auspices of Caroline Calouche & Co. /Charlotte Cirque & Dance Center

I Agree

I will comply with ALL rules both written and verbally stated to me by the Dance & Cirque Staff Caroline Calouche & Co. /Charlotte Cirque & Dance Center. 

I Agree

I understand that Caroline Calouche & Co. /Charlotte Cirque & Dance Center reserve the right to refuse or terminate service to me or my child for any reason not discriminatory, at any time.

I Agree

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
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*
Participant's 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*
Demographic Information
Gender Identity*
Female
Male
Non-binary
Transgender
Intersex
I prefer not to say.
Let me type my response below.

Type response here.
Please indicate your race-ethnicity(ies). Select all that apply. *
American Indian or Alaska Native
Asian or Asian American
Black or African American
Hispanic, Latino, Latina, or Latinx
Middle Eastern or Northern African
Native Hawaiian or Other Pacific Islander
White
I prefer not to answer this question
Another option not listed here (type response below)

Typed response here.
Additional Questions
Student's Preferred Pronouns*
She/Her/Hers
He/Him/His
They/Them/Theirs
Enter preferred pronouns below.

If other, enter preferred pronouns below.

Please list an injuries, previous injuries, allergies or health concerns including mental and behavior that could affect how you learn and ability to accomplish the skills or perform. (i.e. ADD, ADHD, allergic to latex, shoulder surgery, etc.) or none if none. *
How did you hear about us (Select all that apply) *
Camp Guru
Charlotte Magazine
Charlotte Observer
Charlotte Parent
Facebook
Friend
Google Search
Indoor Show
Instagram
Kids Directory
Mailer
Outdoor Show
Private Event or Birthday Party
Radio
Southpark Magazine
Student's Academic School
TikTok
TV
YouTube

If you do not see how you heard above, please share here.
I give my permission for photos and videos of me and/or my child(ren) to be used for marketing purposes.*
Yes
No
May we tag you/your student on Instagram?*
Yes
No

If yes, what is your Instagram handle

Student's Academic School if Applicable
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*

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.


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