Waiver & Release

Bring a Friend Week Waiver

Visiting Child Information

Visiting Child's Name

Friend of (Existing Student)

Visiting Child's Birthday

Allergies or Health Conditions

Parent / Guardian Information

Parent/Guardian Name

Cell Phone

Street Address

City

State

Zip Code

Waiver & Release

I understand that Miller Street Dance Academy (MSDA) assumes no responsibility for injuries or illnesses that may occur as a result of participation in classes or activities.

In case of emergency, I authorize MSDA-selected medical personnel to order X-rays, routine tests, treatment, and hospitalization as deemed necessary for my child's health.

I understand that no accident or medical insurance is provided by MSDA for participants.

I grant permission for MSDA to use photographs, film footage, or recordings of my child for promotional and educational purposes.

I have read and agree to all of the terms above.

Parent/Guardian Signature

Date

Visiting Child Information

Parent / Guardian Information

Waiver & Release

Waiver Submitted