Contact Name: 

Home address:

City:

State: 

Zip:

Email Address:

Home Phone:

Work #:

Cell #:

Alternate cell #: 

Emergency Contact name: 

Emergency Contact cell #: 

 Childs name/Date of birth: 

Childs name/Date of birth: 

Childs name/Date of birth: 

Childs name/Date of birth:

Childs name/Date of birth:

Please list the following from your medical insurance card: 

Insurance Company Name/Phone 

Insured's Name 

Policy Number

Group Number 

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 the 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.

I hereby release and agree to hold Agape Outreach Ministries 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 Outreach Ministries Inc. I understand that this release discharges Agape Outreach Ministries 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 Outreach Ministries Inc., and all ministries. This liability waiver and release extends to all ministries, and employees.

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. 

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.

Digital Signature: