Name of Participant *

First Name

Last Name

Phone Number *

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Participant Date of Birth *

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Email Subscribe

YES I would like to recieve email updates regarding MOVEmeant events and programs.

NO thanks

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

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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.

I agree

Today's Date *

MM

DD

YYYY