Register - Healy School of Irish Dance

Student Name*

First Last

Student DOB*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent 1 Name*

First Last

Parent 1 Email*

Parent 1 Home #*

Parent 1 Mobile #*

Parent 2 Name*

First Last

Parent 2 Email*

Parent 2 Home #*

Parent 2 Mobile #*

Special Needs/Allergies?*

Comments or Questions*

Charges and Payments:

The Healy School accepts payment by personal check or through PayPal. There will be a $40 charge for any returned checks. Tuition is due the first week of each session. All tuition charges are non-refundable. Any attendance during a session constitutes a full fee for the session. Discounts of 10% off the total session are given to families with three or more children enrolled. Make-up classes must be made within one month of the missed class.

Release and Waiver of liability:

As the legal parent or guardian, I hereby give approval for each student Dancer's enrollment and participation in the Healy School and all of the associated activities involved therein. Each student Dancer's participation in the Healy School and all of its activities is by choice, and is completely voluntary. In my capacity as parent/legal guardian for each student Dancer, I agree on behalf of myself, the above-named student Dancer(s), my spouse (if any), my heirs, assigns, etc., to hereby release, waive, absolve, discharge and agree to hold harmless the Healy School, its related entities, trustees, directors, officers, employees, agents and insurers from and against any and all rights, claims, demands, causes of action, obligations, suits, liens, damages or liabilities of any kind and character whatsoever, whether known or unknown, suspected or claimed, which each student Dancer shall or may have in the future against the Healy School arising out of, based on, related to or connected with each student Dancer's enrollment and participation in the Healy Schools program and any of its activities and/or the activities of its related entities. I, on behalf of myself and the individuals and entities referred to above, also agree to indemnify and hold the Healy School harmless from the payment of any and all judgments, settlements, costs, disbursements and attorney fees that are associated with the Healy School having to defend or investigate any claim, action or proceeding of any type whatsoever arising out of the student Dancer's enrollment or participation in the Healy Schools program and activities. I represent and warrant that I have the full power, capacity and authority to execute this document as the parent or legal guardian of each student Dancer. I further represent and warrant that I understand the terms and provisions of this document and its nature and effect. This document is made, executed and entered into and shall be governed by the laws of the state of my residence. I expressly consent to venue and jurisdiction of the courts of my state with respect to any dispute arising out of each student Dancer's enrollment and participation in the above-referenced Healy School and associated activities.

Medical Emergency:

The undersigned gives permission to the Healy School of Irish Dance, its owners, teachers and operators to seek medical treatment for the participant in the event they are not able to reach a parent or guardian. I hereby declare any physical/mental problems, restrictions, or condition and/or declare the participant to be in good physical and mental health.

Media Release:

As the legal parent or guardian, I consent to the release/use of photographs/videos by media/social media (i.e., Facebook, Instagram, TV stations, newspapers (online/print), radio stations, etc). I also grant the Healy School the right to photograph my student(s)/Dancer(s) and use the photo(s) and or other digital reproduction of him/her or other reproduction of his/her physical likeness for publication processes, whether electronic, print, digital or electronic publishing via the Internet indefinitely. I hereby waive any right to inspect or approve the finished photographs or printed or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the photograph. I hereby agree to release, defend, and hold harmless the Healy School and its agents or employees, including any firm publishing and /or distributing the finished product in whole or in part, whether on paper, via electronic media, or on websites, from and against any claims, damages or liability arising from or related to the use of the photographs, including but not limited to any misuse, distortion, blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction or production of the finished product, its publication or distribution.

I have read the release and waiver of liability, medical emergency, and media release and agree to the terms above*

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