Summer Programs

Required Form

Acknowledgement and Release for Participation in In-Person Activities

This form lets your child participate in MSDA’s in-person classes and events while acknowledging the risks

Miller Street Dance Academy, LLC ("MSDA") offers students the opportunity to participate in a variety of in-person activities including classes, lessons, camps, competitions, recitals, and other programs or events. Participation in these activities is voluntary. All parents and guardians signing this acknowledgement and waiver do so knowingly, willingly, and of their own free will.

This Acknowledgement and Release must be completed, signed, and submitted to MSDA before a student is allowed to participate in any in-person activities. No student will be allowed inside the MSDA studio unless and until MSDA has received this completed and signed Acknowledgement and Release.

I recognize that programs at MSDA require physical exertion that may be strenuous and involve inherent risks of serious physical injury (including death). I also recognize that most MSDA programs, by their nature, place students in close physical proximity with other students, and that these activities carry an inherent risk of injury and illness. I KNOWINGLY AND VOLUNTARILY ASSUME ALL SUCH RISKS, EVEN IF ARISING FROM THE NEGLIGENCE OF THOSE PERSONS AND ENTITIES RELEASED FROM LIABILITY BELOW, AND I ACCEPT AND ASSUME FULL RESPONSIBILITY FOR ANY AND ALL INJURIES AND HARM TO STUDENT THAT MAY ARISE AS A RESULT OF STUDENT'S PARTICIPATION.

I understand that the activities involved in MSDA programs are only suggested, and that not everything will be appropriate for everyone. I accept responsibility for assuring that Student will: listen to his/her own body; be aware of any physical conditions that limit his/her ability to participate in any particular activity; not engage in any activity beyond his/her personal limitations; and seek immediate medical attention if injured.

I understand that it is my responsibility to consult with a physician prior to Student's participation in any MSDA program to determine the appropriateness of Student's participation. I represent and warrant that Student is physically fit and does not have any condition that would make participation in MSDA programs inadvisable.

I understand that MSDA does not carry medical insurance for Student. I agree to maintain sufficient medical insurance and to pay all costs associated with any injuries and illnesses that may occur as a result of Student's participation in MSDA programs.

IN CONSIDERATION OF STUDENT BEING PERMITTED TO PARTICIPATE IN MSDA PROGRAMS, I, ON BEHALF OF STUDENT, MYSELF, STUDENT'S OTHER PARENT AND GUARDIAN(S) (IF ANY), AND OUR RESPECTIVE HEIRS AND ASSIGNS (THE "RELEASORS"), HEREBY HOLD HARMLESS, WAIVE, AND RELEASE MSDA AND ALL ITS OWNERS, OFFICERS, DIRECTORS, REPRESENTATIVES, EMPLOYEES, AGENTS, VENDORS, CONTRACTORS, INSURERS, SUCCESSORS, AND ASSIGNS (COLLECTIVELY, THE "RELEASEES") FROM AND AGAINST ANY AND ALL LIABILITY, CLAIMS, ACTIONS, AND CAUSES OF ACTION, WHETHER KNOWN OR UNKNOWN, WHETHER NOW EXISTING OR ACCRUING IN THE FUTURE, ON ACCOUNT OF PERSONAL INJURY, ILLNESS, DEATH, PROPERTY DAMAGE, OR OTHER LOSS ARISING OUT OF OR RELATED IN ANY WAY TO STUDENT'S PARTICIPATION IN MSDA PROGRAMS. THIS RELEASE SPECIFICALLY INCLUDES INJURY, ILLNESS, DEATH, PROPERTY DAMAGE, AND OTHER LOSS CAUSED BY THE NEGLIGENCE OF MSDA AND/OR OTHER RELEASEE(S), BUT EXCLUDES INJURY, ILLNESS, DEATH, PROPERTY DAMAGE, AND OTHER LOSS CAUSED BY THE GROSS NEGLIGENCE OR WILLFUL OR WANTON MISCONDUCT OF MSDA AND/OR OTHER RELEASEE(S). WE COVENANT THAT NEITHER WE, NOR STUDENT, NOR THE OTHER RELEASORS WILL MAKE OR BRING ANY SUCH CLAIM AGAINST MSDA OR ANY OTHER RELEASEE, AND WE FOREVER RELEASE AND DISCHARGE MSDA AND ALL OTHER RELEASEES FROM LIABILITY UNDER SUCH CLAIMS.

In the event that Student is a minor: I warrant and agree that I am the parent or legal guardian of Student; that I have the legal right to consent to this Acknowledgement and Release on behalf of Student, myself, Student's other parent and guardian(s), if any, and our heirs and assigns; and that by signing below, we hereby do consent to the terms and conditions of this Acknowledgment and Release.

In the event that Student is not a minor: I warrant and agree that by signing below, I do hereby consent to the terms and conditions of this Acknowledgment and Release on my own behalf as the Student.

My signature on this form also indicates that I am aware and agree that my student may be included in photos that are used for media purposes.