I, hereby agree to the following:
That I am participating in the Zumba, Stress Release, Hip Hop, Boot Camp, Modern Dance
class(es) during which I will receive and follow instruction.
I understand that it is my responsibility to consult with a physician prior to and regarding my
participation in this/these class(es). I represent and warrant that I am physically fit and I have
no medical condition that would prevent my full participation in this/these class(es).
In consideration of being permitted to participate in this/these class(es), I agree to assume full
responsibility for any risks, injuries or damages, known or unknown, which I might incur as a
result of participating in the program.
In consideration of being permitted to participate in this/these class(es), I knowingly,
voluntarily, and expressly waive any claim I may have against VerLyn Music, or the class
instructor(s) and/or assistants /tutors for injury or damages that I may sustain as a result of
participating in the program.
I, my heirs or legal representatives forever release, waive, discharge, and covenant not to sue
VerLyn Music or any associate/instructor/tutor of VerLyn Music for any injury or death caused
by negligence or other acts.
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I have read the above release and waiver of liability and fully understand its contents. I voluntarily
agree to the terms and conditions stated above
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NAME OF PARTICIPANT:
SIGNATURE OF PARTICIPANT:
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NAME OF PARENT/GUARDIAN:
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SIGNATURE OF PARENT/GUARDIAN
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DATE:
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EMERGENCY CONTACT NAME:
PHONE:
