If you or your child is participating in our programs, please read carefully and fill out the form below, and accept that you have understood by typing your name as a signature at the end. Thank you for your cooperation. 

Name of Participant *
Name of Participant
Phone Number *
Phone Number
Participant Date of Birth *
Participant Date of Birth
Email Subscribe
Describe Below
Emergency Contact *
Emergency Contact
Emergency Contact Phone *
Emergency Contact Phone
I have read, understood, and agree to be bound by the statement below *
*AGREEMENT AND ASSUMPTION OF RISK I (named above), understand and agree that in participating in any movement/dance class, workshop, or program with “MOVEmeant”, there is a possibility of accident or injury. I voluntarily agree to assume all risks and responsibility for any such injury or accident, which might occur to me (or my child, if participant under 18), during any “MOVEmeant” classes, workshops, or programs. I also exempt, release, and indemnify “MOVEmeant”, its owners, agents, volunteers, assistants, employees, contractors, partners, and/or students from any and all liability claims, demands, or causes of action whatsoever from any damage, loss, injury, or death to me, (my children, if under 18), or property which may arise out of or in connection with participation in any activities conducted by “MOVEmeant”. I understand that I am expected to be aware of my own physical limitations, and agree not to exceed them. (If participant is under 18, I certify that I am the parent or legal guardian of the child named below, and have the right to waive these rights). By signing below, I agree that I have read, understood, and agree to be bound by the above statement.
Today's Date *
Today's Date
By typing your name below, you are agreeing to the terms indicated in the Registration and Liability Form