WAIVER AND RELEASE OF LIABILITY

LANISINA POLYNESIAN DANCE ACADEMY

IN CONSIDERATION OF the risk of injury that exists while participating in LANISINA POLYNESIAN DANCE ACADEMY activities and your desire to participate, please read this waiver carefully and provide your information below.

Participant First Name

Participant Last Name

Date of Birth

Month

Day

Year

Required to determine if parent/guardian signature is needed

Email Address

Phone Number

Address

Full address of participant

I acknowledge that I am voluntarily participating in LANISINA POLYNESIAN DANCE ACADEMY activities entirely at my own risk and am aware of the risks associated with participating, which may include physical or psychological injury, pain, suffering, illness, temporary or permanent disability, economic or emotional loss, and death.

I hereby waive any and all rights, claims or causes of action arising out of my participation and release LANISINA POLYNESIAN DANCE ACADEMY, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns from any physical or psychological injury.

I agree to indemnify, defend and hold harmless the releasees against any claims, suits or actions brought by me or anyone on my behalf, including attorney's fees and related costs.

I authorize LANISINA POLYNESIAN DANCE ACADEMY to provide emergency medical care if needed and agree to assume all costs involved and be financially responsible for any treatment costs.

I grant permission for LANISINA POLYNESIAN DANCE ACADEMY to use my likeness in

Select all that apply (optional)

Emergency Contact Name

Emergency Contact Phone

Relationship to Emergency Contact

Medical Conditions or Allergies

Please list any medical conditions, allergies, or medications that may be relevant (optional)

I certify that I am medically able and properly trained to participate, and I agree to abide by the decision of LANISINA POLYNESIAN DANCE ACADEMY officials regarding my approval to participate. I also agree to follow all rules that apply to uniform and costume requirements, and understand that if I do not meet these requirements, I will not be able to participate. I understand that if I join the school, I cannot post or share any inside information of LANISINA without the director's agreement.

I acknowledge that I have carefully read this waiver and release, fully understand that it is a release of liability, and am signing it of my own free will. I understand this agreement is governed by Florida law and cannot be modified orally.

Participant Signature

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Electronic signature acknowledging agreement to all terms

Date Signed

Month

Day

Year