Because participation in Do Jump Movement Theater School classes may be dangerous, we require all participants to assume all risks by signing this general release, or signifying agreement by submitting this form to us electronically.
First Student name:
First Student birthdate:
Is student new or returning?:
Class registering for (please include term, day, time + age):
Second Student name:
Second Student birthdate:
Parent/guardian name (if applicable):
Address:
Phone number:
Alternate phone:
Your e-mail address:
The above named participant agrees to indemnify and hold harmless Do Jump! and the Echo Theatre (hereinafter referred to as Theater), its Employees, Agents, Officers, Board Members, Volunteers or any other person against loss or expense, including attorney fees, due to any bodily injury, personal injury or property damage which may result from any and all activities while participating in classes or any other activity sponsored by or conducted by Theater, or while visiting any facilities owned by, leased by, or controlled by Theater.
In the event of injury to participant/child and the parent or legal guardian cannot be contacted, please provide the name and telephone number(s) of the relative or friend who should be contacted:
Emergency contact name:
Emergency contact phone #:
Allergies:
Medications (please include instructions for any medication an instructor would need to administer):
Family health care provider:
Provider phone #:
Insurance carrier:
Notes:
To submit your release form, please click "I agree"
