Registration Letter

Photography Release

Student Information

Students Name(Required)
Date of Birth

Parents Information

Parents Name(Required)
(such as heart, back, medical, allergy, muscular, diabetes, epilepsy, chemical or neurological condition, special medical, knee, kidney, etc.)
I understand the risk of injury is inherent in any physical activity and I, on behalf of my child knowingly and voluntarily accept that risk. I the undersigned, for myself, my heirs, administrators, and executors, hereby waive and release Madeleine Walker Coastal Ballet Theater LLC and its staff from any and all claims or damages of any kind arising out of my participation in the exercise or dance program and that he/she has been examined by a licensed physician and found to be in proper physical condition to participate in said program. I, the undersigned, do hereby authorize Madeleine Walker Coastal Ballet Theater LLC or its staff to obtain medical treatment for my said child in emergency situations where I cannot be reached in time to authorize the treating physician to provide such emergency medical services. This includes the power to authorize any and all treatment deemed necessary under the circumstances by a licensed physician. This power is in essence a power of attorney and shall remain in effect from the date signed below.
(If under 18; Parent(s) or Legal Guardian(s) must sign)

Optional information

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