Participant & Primary Contact Information

Name of Participant *

First Name

Last Name

Participant's Date of Birth *

MM

DD

YYYY

Phone of Participant or Primary Contact *

(###)

###

####

Name of Emergency Contact *

First Name

Last Name

Phone of Emergency Contact *

(###)

###

####

Liability Waiver *

I, the parent or legal guardian (now on referred to as Primary Contact) of myself or the child listed in this registration form, realize that participation in dance classes and activities could involve some possible personal injury. Despite precautions, accidents and injuries may occur. By signing this release form, I/we assume all risks related to using any and all spaces used by and programs, activities, rehearsals or shows run by Give Me Brilliance (now on referred to as GMB). I/we agree to release and hold harmless GMB, including its teachers, dancers, staff members, volunteers and facilities used by both entities from any cause of action, claims, or demands now and in the future. I/we will not hold GMB liable for any personal injury or any personal property damage, which may occur on the premises before, during or after classes. Furthermore, I/we agree to obey the class and facility rules and take full responsibility for my/our behaviour in addition to any damage I/we may cause to the facilities utilized by GMB. Finally, I/we agree to inform GMB of any physical limitations my child has before starting any programs with GMB and with the understanding that my child's doctor has approved participation in physical activities such as dance.

Agree

Disagree

Image Capture Waiver *

I, the Primary Contact, understand the Photo and Video Release, or Image Capture Waiver, which means that I agree to the use of images of me or my child by GMB on the GMB website, social media pages, in brochures or in other promotional materials. I understand that no identifying information will be included.

Agree

Disagree