Registration

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Name

to you. to

Phone

Amount Paid

Medical: Do you have any medical concerns or are taking any medication we should be award of? If you answer YES to this question, It is your responsibility to consult with the proper medical authority to determine if this activity is recommended for you.

Emergency Contact Name

Emergency Phone Number

By clicking the box below and printing your name below where it says “Signature”, you are agreeing to the fact that you have read, understood and accepted the above policies and waiver.

I have read, understood, and accepted, the above policies and waiver.

Name

Date

Policies & Waiver

Payment

Payment must be made by E-Transfer only to: [email protected]

Withdrawl and Refunds

No refunds will be given for withdrawal from registered classes (including registered workshops, except for medical reasons and only with a Doctor’s certificate. Colds & Flus do not qualify as a medical reason. Class time due to Colds & Flu can be made up.

The refund amount with a medical Doctor’s certificate will be only for the number of classes remaining in the session, less a $40.00 processing fee for 6 – 8 week sessions. A $60 processing fee will be applied for 8 – 10 week sessions. A $25 processing fee will be charged for a workshop. A maximum processing fee of $100 will be charged to a student who is registered in more than one class per semester.

Photo Release

I am aware and understand that group and individual publicity videos & photos may be taken. I hereby grant permission for my likeness to be used in advertising or publicity for Karen Marie Dance & Fitness.

Missed Classes

If a student misses a class, she or he can take another class offered by Karen Marie Dance & Fitness, after consultation with Karen Iwanski. No transfers of such make-up session will be allowed, either from one session to another, or from one student to another. In the event Karen Marie Dance & Fitness cancels a class (due to instructor illness or otherwise) the same will apply. The studio will make every effort to reschedule such class during the session.

Waiver Release

While Karen Marie Dance & Fitness endeavors to provide a safe and fun atmosphere, the programs and activities by or through Karen Marie Dance & Fitness involve physical acts and may result in injury, or in extreme cases, death. Please consult your physician prior to undertaking any new exercise program or activity. By signing this form, I hereby acknowledge and accept the risks related to the programs I have registered for. I also agree that in consideration for Karen Marie Dance & Fitness providing me with these services, and as a condition to those services being provided, I hereby waive any and all claims that I have or may have in the future against Karen Marie Dance & Fitness, (hereinafter referred to as the Release), and release, and as a separate covenant indemnify the Release from any and all liability for any loss, damage, expense, or injury (including death) that I might suffer or that my next of kin may suffer arising from or connection with my participation in or practicing of any physical training, travel, athletic activity, or consent (including, but not limited to the programs referenced on this form) through, with, in any way involving or in association with Karen Marie Dance & Fitness or the use of or presence on or in premises owned, leased or operated by Karen Marie Dance & Fitness or for the time being used by Karen Marie Dance & Fitness. In addition, Karen Marie Dance & Fitness will not assume liability for any lost or stolen property.

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