AMATEUR ATHLETIC

Inscription
NOM DU DANSEUR:_____________________________________
AGE :__________
SEXE : F
M
TÉLÉPHONE (Maison) :_______________________________ (Cellulaire) :______________________________
COURIEL: __________________________________________________________________________________
ADRESSE:__________________________________________________________________________________
NOM DU/DES PARENT(S) OU TUTEUR :___________________________________________________
GRANDEUR DE T-SHIRT :
ENFANTS : P, M, L, XL
ADULTE: P, M, L , XL
ALLERGIE : _________________________________________________________________________________
ENCERCLEZ VOTRE CHOIX DE CAMP DE DANSE:
Prix: 150$ avant le 10 juin et 160$ après la date limite
HEARST
11 au 14 juillet 2016
PARRY SOUND
25 au 28 juillet 2016
*Les frais d’inscriptions sont non-remboursables
STURGEON FALLS
18 au 21 juillet 2016
NORTH BAY
2 au 5 août 2016
TÉMISCAMING, QC *2 jours seulement*
8 et 9 août 2016 (75$ avant le 10 juin et 80$ après la date limite)
S.V.P. envoyez le formulaire et le coût d’inscription (Argent contant ou chèque) à :
Danse Dynamik/ Dynamic Dance Workshop Company
C/O Stephanie Perron and Mats Vanderlinden
1101 Hwy 17 east
North Bay, On
P1A 0A5
Signature du parent: ___________________________________
DATE:________________________
OUI, J’aimerais un reçu
© Dynamic Dance Workshop Company/ Danse Dynamik 2016
Form 2016
DYNAMIC DANCE WORKSHOP COMPANY/DANSE DYNAMIK
WAIVER AND RELEASE OF LIABILITY
Name of Dancer: ___________________________________
In consideration of being allowed to participate in any way in the Dynamic Dance Workshop Company/ Danse Dynamik
athletic/sports/summer program, related events and activities, the undersigned acknowledges, appreciates, and agrees that:
1.
The risk of injury from the activities involved in this program is significant, including the potential for permanent
paralysis and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury
does exist; and,
2.
I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM
THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,
3.
I willingly agree to comply with the stated and customary terms and conditions for participation. If however I observe
any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the
attention of the nearest official immediately; and,
4.
I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND
HOLD HARMLESS Dynamic Dance Workshop Company/ Danse Dynamik,
their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable,
owners and lessors of premises used to conduct the event (“Releasees”), WITH RESPECT TO ANY AND ALL INJURY,
DISABILITY, DEATH, or loss or damage to person or property, WHETHER CAUSED BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE.
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS
TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY
AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
THIS IS TO CERTIFY THAT I, AS PARENT/GUARDIAN WITH LEGAL RESPONSIBILITY FOR THIS PARTICIPANT, DO
CONSENT AND AGREE TO HIS/HER RELEASE AS PROVIDED ABOVE OF ALL THE RELEASEES, AND, FOR
MYSELF, MY HEIRS, ASSIGNS, AND NEXT OF KIN, I RELEASE AND AGREE TO INDEMNIFY THE RELEASEES
FROM ANY AND ALL LIABILITIES INCIDENT TO MY MINOR CHILD’S INVOLVEMENT OR PARTICIPATION IN
THESE PROGRAMS AS PROVIDED ABOVE.
X _________________________________________
PARENT/GUARDIAN’S SIGNATURE
___________________________________
EMERGENCY PHONE NUMBER
Date Signed: _______________________
PHOTO/VIDEO RELEASE FORM
I hereby give permission for images of my child, captured during regular and special Dynamic Dance Workshops Company/
Danse Dynamik activities through video, photo and digital camera, to be used solely for the purposes of Dynamic Dance
Workshops Company/ Danse Dynamik promotional material and publications, and waive any rights of compensation or ownership
thereto.
I consent
I DO NOT consent
________________________________
PARENT/GUARDIAN’S SIGNATURE
© Dynamic Dance Workshop Company/ Danse Dynamik 2016
Form 2016