top of page
Use theatre and dance to spark a revolution,
to change the world.
513.ARTS.123
Informed Consent
Please fill out the following form
in order to participate in our programs.
Has the participant been hospitalized in the last 12 months?
No
Yes
Is the participant suffering from a medical condition, illness, or injury?
No
Yes
If you answered yes to any question, please elaborate
I understand that in my participation, exercises involved may include aerobic activities, walking, running, dancing and/or other vigorous physical activity.
I understand that with my voluntary participation, I will be given instruction suitable for the improvement of dance technique as well as the benefit of my cardiorespiratory (heart and lungs), musculoskeletal (muscles, joints, and bones), and overall body fitness.
I understand that during the conduct of exercise, the reaction of my heart, lungs, and blood vessels, etc., cannot be predicted with accuracy, thus risks may arise due to adverse changes of that may lead to heart attack, high blood pressure, or stroke.
I was given information and I understand that during training, injuries may arise such as muscle, ligaments, joints and tendons; and in I have been given proper information in order to prevent or minimize these occurrences.
I was given information and I understand that during training, injuries may arise such as muscle, ligaments, joints and tendons; and in I have been given proper information in order to prevent or minimize these occurrences.
I understand that I shall solely be responsible, and the fitness center shall not be held liable for any damages and injuries arising from my participation with Revolution Dance Theatre.
I was given information and I understand that during training, injuries may arise such as muscle, ligaments, joints and tendons; and in I have been given proper information in order to prevent or minimize these occurrences.
I was given information and I understand that during training, injuries may arise such as muscle, ligaments, joints and tendons; and in I have been given proper information in order to prevent or minimize these occurrences.
I hereby release and fully and forever discharge Revolution Dance Theatre, its assigns and agents from any and all claims, demands, and/or damages therein.
I declare that the info I’ve provided is accurate & complete
Select an option
I am of legal age and I am legally competent to give my consent to this agreement.
I am below legal age or I am not competent to sign this agreement. My Parent/Guardian/Representative shall sign this informed consent on my behalf.
Participant First Name
Participant Last Name
Parent/Guardian/Representative First Name
Parent/Guardian/Representative Last Name
Email
Date of Birth
Your Signature
Clear
Submit
Thanks for submitting!
bottom of page
.png)