Dance4Epilepsy Registration

DestinyMaker Dance4Epilepsy

– REGISTRATION FORM –

Studio Name

Contact Name

Contact Phone

By clicking “Submit,” I agree to the terms above

Address

City

Zip

Agreement

I, the Studio applicant or I, any parent or legal guardian of the dancer listed below, hereby give approval of the applicant’s participation in any and all DestinyMaker events and programs and activities registered below. I do waive, release, absolve, indemnify and agree to hold harmless the organizers, sponsors, supervisors, participants and persons involved in the operation of DestinyMaker programs for any claims arising out of injury or other loss to named applicant or any member of his/her family whether as a participant in the activities or as a spectator. I also give permission for DestinyMaker to use photos of event or participants to use for the website and for purposes of promoting the event. If any child exhibits behavior that is dangerous to herself/himself or to other students, DestinyMaker reserves the right to remove the child from the event.

State

Name M/F DOB

List Participants