THE
JOFFREY WORKSHOP TX
and
St. Mary’s University
Waiver of Liability and Hold Harmless
Agreement
- In
the consideration of The Joffrey Workshop TX providing the
opportunity for and permitting the undersigned (Participant) to
participate and take part in The Joffrey Workshop TX and its
related activities,
June 26, 2010 to July 17, 2010 the undersigned Participant and Parent of the Participant, do hereby
release, remise and forever discharge, indemnify and agree to HOLD HARMLESS
WAIVE, DISCHARGE, and COVENANT NOT TO SUE The Joffrey Workshop TX,
its officers, employees, faculty, instructors, servants, agents and
assigns, hereinafter referred to as RELEASEES, from any claim,
demand or cause of action whether now in existence, or hereafter
arising for any loss of personal property, injury to the Participant or
for the death of the Participant, arising out of resulting from, caused
by or contributed to in whole or in any part by any action or failure to
act, negligence, breach of contract, or other misconduct on the part of The
Joffrey Workshop TX, its officers, faculty, agents, servants, employees,
(RELEASEES) any other Participant in said workshop, any participating
parent and/or any one or more of any thereof.
- We
recognize and acknowledge that certain risks of harm are or may be
inherent in the various activities contemplated herein and that The Workshop or University cannot control all of these risks. We are
aware that ballet training and the gymnastic exercises associated with it
place unusual stress on the body and carry with them the risk of physical
injury. I / We assume the risks involved. I / We also understand that
dance instruction involves kinetic correction that may include physically
touching the student (Participant) as part of the regular class work
and/or rehearsal. I / We assume the risk and agree that The Joffrey
Workshop TX faculty have permission to engage in appropriate kinetic
correction of the body for technical corrective purposes as part of
regular class work and rehearsal.
- It
is my/our express intent that this Release and Hold Harmless Agreement
shall bind the members of my/our family if I am alive, and my heirs,
assigns and personal representative, if I am not alive. It shall be
deemed as a RELEASE, WAIVER, DISCHARGE, AND COVENANT NOT TO SUE the above
named RELEASEES. I hereby further agree that this Waiver of Liability and
Hold Harmless Agreement shall
be construed in accordance with the laws of the State of Texas.
- I
UNDERSTAND THAT THE JOFFREY WORKSHOP WILL NOT BE RESPONSIBLE FOR
ANY MEDICAL COSTS ASSOCIATED WITH ANY INJURY THAT I OR MY CHILD MAY
SUSTAIN.
5. I / We also
understand that I / we should and am / are urged by RELEASSEES to obtain health
and accident insurance to cover any personal injury to me / my child
(Participant), which may be sustained.
6. I / We agree that I
or my child (Participant) will adhere to the Rules and Regulations promulgated
by The Joffrey Workshop TX and obey all
laws of the State of Texas while
participating in this activity.
IN
SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT I / We have read
the foregoing Waiver of Liability and Hold Harmless Agreement, understand
it and sign it voluntarily as my / I own free act and deed; no oral representations,
statements or inducements, apart from the foregoing written agreement,
have been made; I am at least eighteen (18) years of age and fully competent
or, if I am under eighteen (18) years of age, my parent or legal guardian’s
approval and signature has been obtained; and I / we execute this Release
for full, adequate, and complete consideration fully intending to be bound
by the same.
IN WITNESS WHEREOF, I have hereunto set my
hand on this _______ of _______, 20_____
Day
Month Year
Student Name:
_________________________________________________________________
Please Print
If 18 years of age or
over: Yes __________ No __________
Participant
Signature: _________________________________________ Date: _______________
Participant Printed
Name: __________________________________________________________
Participant Address:
_______________________________________________________________
Participant Home Phone
Number: ____________________________________________________
Participant Cell #:
_________________________ Email Address: __________________________
EMERGENCY INFORMATION: Person(s)
to be contacted in case of emergency:
Name: Relationship:
_______________________________________________________________________________
Phone Numbers:
Home: ___________________________________ Cell: _________________________________
Work: ___________________________________ Other: ________________________________
Email Address: _________________________________________________________________
HEALTH INSURANCE AND
POLICY NUMBERS:
Name of Insurance Company: ____________________________________________________
Health Insurance
Group Number: _________________________________________________
Policy Number: ________________________________________________________________
Address: _____________________________________________________________________
City: _______________________________________ State: ___________ Zip:_____________
Insurance Company Telephone Number: ___________________________________________
*****************************************************************************************************************
WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT
If
I am under the age of eighteen, I have read, understood, and discussed the
above content with my parent or guardian identified below. We hereby accept the
terms and conditions as stated in this document.
______________________________________ ____________________________________
Participant Signature Age Parent
/ Guardian Signature
______________________________________ ____________________________________
Printed Name
Printed Name
______________________________________ ____________________________________
Address Address
______________________________________ ____________________________________
City / State / Zip
City / State / Zip
______________________________________
____________________________________
Date
Date