offsite class waiver

LIABILITY WAIVER

All dancers registered for an offsite class with PopRox must have this form filled out by or before their first class wt PopRox.

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Dancer’s Name

First Name

Last Name

Email

Which organization are you affiliated with?

School name or location hosting the class

LIABILITY AGREEMENT

I hereby authorize representative of PopRox Dance LLC, including employees, directors, or identified volunteers, to serveas agents for my child to consent to any emergency medical care, including x-ray exam, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by and is rendered under the general or specific supervision of any licensed physician or surgeon on the medical staff of any hospital licensed by the State of Washington whether such diagnosis or treatment is rendered at the office of said physician or at said hospital or some other site. I also understand and agree that PopRox Dance shall not be held responsible for any injuries, damage, or personal loss which might occur while attending or participating in any PopRox function. The authorization shall remain valid for the duration of your child’s registration with PopRox Dance. By registering for class, you agree to comply with our terms of service and policies listed on the following pages: -www.poproxdance.com/terms-service -www.poproxdance.com/privacy-policy -www.poproxdance.com/anti-harassment

Date:

MM

DD

YYYY

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