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2021-2022 Session/Masterclass Registration

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WELCOME TO AGAPE ARTS CENTER 2021-2022! 

Please fill out 1 form PER FAMILY

By completing the following digital agreement, I acknowledge that I have read and agree with the content in it's entirety 

FAMILY INFORMATION:

1. *

Contact Name: 

2. *

Home address:

3. *

City:

4. *

State: 

5. *

Zip:

6. *

Home Phone:

7. 

Work #:

8. *

Cell #:

9. *

Alternate cell #: 

10. *

Emergency Contact name: 

11. *

Emergency Contact cell #: 

12. *

 Childs name/Date of birth: 

13. 

Childs name/Date of birth: 

14. 

Childs name/Date of birth: 

15. 

Childs name/Date of birth:

16. 

Childs name/Date of birth:

17. *

Please list the following from your medical insurance card: 

Insurance Company Name/Phone 

Insured's Name 

Policy Number

Group Number 

18. *

RELEASE FROM LIABILITY: I hereby release Agape Arts Center from any liability for any accident or injury occurring on or around the studio premises, or at any function at other locations in conjunction with Agape Art Center. I declare the student(s) named above is in good health and can participate in the enrolled classes. Given the nature of dance classes, and knowing that injuries sometimes occur, I have taken necessary steps to obtain health, accident, hospital and/or other insurance, which would cover any sustained injuries. In the event of an injury or emergency, if I am unable to be contacted, I give permission for Agape Arts Center to obtain medical services for this student.

COVID-19 WAIVER I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.

I further acknowledge that Agape Bible Church Inc., and all ministries have put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.

I further acknowledge that Agape Bible Church Inc., cannot guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of others, including, but not limited to, parents, teachers, students, and their families.

I voluntarily seek services and am choosing to participate in events provided by Agape Bible Church Inc, and/or its affiliated ministries and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending any event including, but not limited to services, classes, and functions.

I attest that myself and no member of my family will participate in any dance related classes or events at/with Agape Arts Center if any of the following cannot be stated and agreed upon from September 1, 2021-August 31, 2022.

* I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.

* I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.

* I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non-contagious by state or local public health authorities.

* I am aware of CDC recommended guidelines and as much as possible am limiting my exposure to the Coronavirus/COVID-19.

I hereby release and agree to hold Agape Bible Church Inc. harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the organization, or that may otherwise arise in any way in connection with any services received from Agape Bible Church Inc., and all ministries. I understand that this release discharges Agape Bible Church Inc., and all ministries from any liability or claim that I, my heirs, or any personal representatives may have against the organization with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Agape Bible Church Inc., and all ministries. This liability waiver and release extends to the church and all ministries, and employees.

 (1 required)
I've read the above and agree
19. *

MEDIA RELEASE:

Agape Arts Center may at time take photographs of classes, students, and student performances for use in our publications and on our website and social media pages for development and promotional purposes. All photographs are taken and used in a professional manner only. If you prefer NOT to have your student photographed, please submit your request in writing. 

 (1 required)
I've read the above and agree
20. *

WITHDRAWAL/ABSENCE:

All classes scheduled per session are non-refundable and there are no make-ups for sickness.

Extenuating circumstances may include but is not limited to: 

  • Death of an immediate family member
  • Traumatic and unforeseen circumstances that are considered beyond the family's control
  • Physical injury or illness that has resulted in the student’s inability to complete the session. 
  • Financial hardship 

Agape Arts Center hires teachers for a session and have a responsibility to keep our commitment to them. Families should note that a students desire to not continue in class does not constitute an extenuating circumstance in and of itself and withdrawals due to such reasons.

 

 (1 required)
I've read the above and agree
21. *

Digital Signature: