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Due to the 2019-2020 outbreak of the Coronavirus (COVID-19), our business is taking extra precautions with the care of every dancer, student, and client to include health history review and enhanced sanitation/disinfecting procedures in compliance with CDC guidance.

 

COVID-19 is a contagious virus that spreads from person to person. In addition to our regualr cleaning policies and procedures that this business has in place, additional preventative measures are being followed to further reduce the spread of this novel coronavirus. However, please know that these best practices still offer no guarantee and there is a potential risk of becoming infected. 

 

Consent for Business Service

I understand that this business service includes physical touch and close proximity over an extended period of time.  Because of this, there may be an elevated risk of disease transmission, including COVID-19.   By signing this form, I acknowledge that I am aware of the risks involved from receiving service from this business at this time.  I voluntarily agree to assume those risks, and I release and hold harmless this business from any and all claims related to receiving service.  I give my consent to receive service from this business.   

I Agree
June 28, 2022

First Participant's Name

First Name*

Last Name*
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*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Answer Questions Below
In the past 48 hours have you had any cough, sore throat, shortness of breath or flu-like symptoms?*
No
Yes
In the past 48 hours have you had any fever, headache, muscle aches, lost of taste, lost of smell?*
No
Yes
Have you been diagnosed with COVID-19 in the past 14 days?*
No
Yes
Have you been in contact with anyone in the past 14 days that has symptoms or have been diagnosed with COVID-19?*
No
Yes
Have you traveled in the past 14 days to any regions affected by COVID-19?*
No
Yes
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*
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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