top of page
Youth Program Header (1).png

Liability Waiver and Release Form

The following form must be completed for each student ​prior to participation. 

  1. Student Information

Date of Birth
Month
Day
Year

Please enter a grade number between 2 and 12.

Preferred Pronouns

This information is collected to help our instructors address students appropriately and foster an inclusive environment.

Any prior dance experience?
Yes
No

  1. Parent / Guardian Information

Primary Parent / Guardian

This phone number can receive texts
Yes
No
This phone number can receive texts.
Yes
No

Home Address

Multi-line address

Secondary Parent / Guardian (optional)

This phone number can receive texts.
Yes
No

  1. Emergency Contact Information

(Other than parents / guardians listed above)

Emergency Contact #1:

Emergency Contact #2 (optional):

  1. Medical Information

Does your child have any allergies?
Yes
No
Does your child have any medical conditions, injuries, or physical limitations we should be aware of?
Yes
No
Is your child currently taking any medications?
Yes
No

  1. Authorization for Emergency Medical Care

In the event of an emergency, I authorize Dance Masters Performing Arts and its representatives to seek and obtain emergency medical care for my child if I cannot be reached. I understand that every effort will be made to contact me before such action is taken.

  1. Liability Waiver and Release

I/we acknowledge and agree on behalf of ourselves, and if the student registering is a minor, on behalf of such minor student (I/we and such a student, if a minor, are hereafter referred to collectively as the "Student") that Student's use of Dance Masters Ballroom in Agoura Hills ("Studio") studio facilities, services, equipment, or premises, involves risks of injury to persons and property, including those described below, and I/we the Student assumes full related Studio events, for any purpose, whether or not as the Studio's facilities, including but not limited to, instruction, observation, use of facilities, services, equipment, or participation in any way, Student agrees to the following: Student hereby releases and holds Studio, its managers, members, officers, contractors, employees, and agents ("Studio Parties") harmless from all liability to Student and Student's personal representatives, assigns, heirs and next of kin for any loss and/or damage, and waives any claim or demands therefore, on account of injury to Student's person or property.


Student represents (a) that Student is in good physical condition and has no disability, illness, or other condition that could prevent Student from dancing and/or exercising without injury or impairment of health, and (b) that Student has consulted a physician concerning a dance and/or exercise program that will not risk injury to Student or impairment of Student's health. Such risk of injury includes (but is not limited to): injuries or medical disorders arising from dance and/or exercise activities at the Studio's facilities or at Studio related events; injuries or medical disorders arising from exercising such as heart attacks, strokes, heat stress, sprains, broken bones and torn muscles and ligaments, among others; and accidental injuries occurring anywhere in Studio's facilities. Student further expressly agrees that foregoing release, waiver and agreement is intended to be as broad and inclusive as is permitted by law of the State of California.

  1. Photo and Video Release

Choose one of the following:
I give permission for Dance Masters Performing Arts to use photos or videos of my child for promotional purposes, including social media and marketing materials. Personal identifying information will not be included. I authorize Dance Masters Performing Arts, its assigns and transferees to copyright, use and publish the same in print and/or electronically.
I do NOT give permission for my child's photo / video to be used.

  1. Acknowledgment and Signature

By signing below, I acknowledge that I have read, understood, and agreed to the terms outlined in this form. I affirm that all information provided is accurate and complete. I understand that a typed name below constitutes a valid electronic signature.

bottom of page