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Based upon the need to address safety conerns relatied to COVID-19, the Safety First Partnership Agreement is between the Charlotte Cirque & Dance Center, the student, their parent(s)/legal guardian(s), and their family.  Each time you are coming into our facility, you agree to the following.

The Safety First Partnership Agreement is between the Charlotte Cirque & Dance Center, the student(s), their parent(s)/legal guardian(s), and their family.  Each time you are coming into our facility, you agree to the following:

To the best of my knowledge, I/my child:

Have not shown symptoms of COVID-19 in the past 14 days. According to the Center for the Disease Control, below are symptoms:

  • Cough
  • Shortness of breath or difficulty breathing
  • Fever
  • Chills
  • Repeated shaking with chills
  • Muscle pain
  • Headache
  • Sore throat
  • New loss of taste or smell

I Agree

Have not been in contact with anyone who has tested positive for COVID-19 or shown any of the above symptoms in the past 14 days.

I Agree

Have worn a protective mask when in public situations where social distancing is not consistently possible.

I Agree

Understand that I could be a carrier of COVID-19 and be asymptomatic.

I Agree

Understand that I could contract COVID-19 from an asymptomatic person at our facility or a contaminated surface.

I Agree

Am fully aware of the facility's safety procedures listed on our website to prevent the spread of COVID-19 and will follow these procedures.

I Agree

Agree to inform the studio/school immediately if I have developed symptoms within a two week period of being in the studio, or if I have learned that I have been in direct contact with someone who has later tested positive for the coronavirus within the same two week period or traveled in the past 14 days to an area identified as a hotspot.

I Agree

Understand that if I willfully and intentionally violate the stated hygiene rules in our facility, the facility has the right to suspend me without a refund.

I Agree

Agree to inform the studio/school immediately if I learn that any of the above information changes or I obtain new information.

I Agree

Understand that this policy may be updated at any time, and I may be asked to sign or agree to changes at any time in order to continue my use of Charlotte Cirque & Dance Center classes or facilities."

I Agree

I have read and understand the above information and agree to not hold Charlotte Cirque & Dance Center / Caroline Calouche & Co. or any of its employees liable if I or a family member contract COVID-19 during the time that I am attending or making use of their facility.

I Agree

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

Email*

Confirm Email*
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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*

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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