Student's Name *

First Name

Last Name

Student's Date of Birth *

MM

DD

YYYY

Parent's Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you a RB Swim & Tennis Club Member? *

Yes

No

How did you hear about SBSD?

Friend (let us know who!)

Instagram

Facebook

Google

Yelp

S&T Club Member

Walk-In

Other

Class Selection *

6-8 years (9-10am)

9-12 years (10-11am)

13 years and up (11-12pm)

Payment Agreements: *

PAYMENT AUTHORIZATION: I authorize LILACK INC. dba STEP BY STEP DANCE to charge the $85/per student tuition fee using the card on file. CANCELLATION POLICY: I understand that there are no refunds or credits for cancellations once this registration has been processed.

I agree to the above

Waiver Agreements: *

MEDIA RELEASE: Pictures & video clips of class work and/or performances may be taken by Step by Step Dance and posted on the studio website, social media pages, and used in printed and online promotional material for the studio. I understand that names and/or personally identifiable information is never associated with the images and/or video clips used. I hereby grant Step by Step Dance a non-exclusive, royalty-free, perpetual license and permission to use, exploit, adapt, modify, reproduce, distribute, publicly perform and display, in any form now known or later developed, me or my child’s image or visual likeness and/or my or my child’s voice (“Personal Image”) throughout the world, by incorporating it or them into publications, videos, webcast and/or other media (“Works”) or commercial, informational, educational, advertising or promotional materials related thereto. My child and I waive any right to inspect or to approve any Works that may be created using the Personal Image and waive any claim with respect to the eventual use to which the Personal Image may be applied. I understand and agree that Step by Step Dance is and shall be the exclusive owner of all right, title, and interest, including copyright in the Works, and any materials containing the Personal Image. ASSUMPTION OF RISK: I understand that my participation, or that of my child(ren), in the activities at Step By Step Dance is optional. I understand that these activities involve stretching and mild to vigorous cardiovascular exercise. I acknowledge that dance requires physical exertion and can be a HAZARDOUS RECREATION ACTIVITY with RISK of physical injury, and I am aware of the risks and hazards involved, including sprains, falls, muscle injury and torn ligaments. This is not a complete description of all risks and that other unknown or unforeseen hazards and risks of harm may occur. With this in mind, I accept full responsibility for me and my child(ren)’s safety and EXPRESSLY ASSUME ALL RISKS OF HARM as a result of participating in these classes, whether foreseen or unforeseen, regardless of location. HEALTH REPRESENTATION: I represent that me or my child(ren) are in good health and suffers from no physical impairment that would limit his/her participation in these classes. I understand that it is my responsibility to consult with a physician prior to and regarding me or my child(ren)’s participation in these classes. RELEASE OF LIABILITY: I HEREBY WAIVE, RELEASE, AND DISCHARGE Step By Step Dance, Lilack Inc., Ryane Jollon, employees, agents or independent contractors (“Representatives”)from any and all claims which may arise due to an injury, ailment, death, disability, property damage, or illness directly or indirectly related to my, or my child(ren), participating in the activities of Step By Step Dance, including without limitation, those caused by epidemics, pandemics, accidents, third party criminal acts, natural disasters and/or acts of God. I HEREBY AGREE TO INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE Step by Step Dance and its Representatives, and release them from any and all liabilities or claims made as a result of participation in these classes and related events, whether caused by the negligence of release or otherwise. I acknowledge that neither Step By Step Dance, nor its owners, employees, agents and independent contractors are licensed medical practitioners. In the event of a medical emergency, every effort will be made to reach parents immediately. If unable to reach you, this authorizes Step By Step Dance to call 911. I intend for this agreement to bind me, my child(ren), and our assigns, estate, heirs and personal representatives. I have carefully read the above Release of Liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above.

I agree to the above.