Special Activities Release Form

Date of Activity:___________________

 Child’s Name:____________________________________________ Emergency Phone:________________________

 Age:__________   Birth Date:_______/_______/_______  Current Triplett & Propst Student:   YES   NO

(If NOT a current student please fill out the information below.)

Parents Name:_______________________________________________________________________

Email:______________________________________________________________________________

 Address:____________________________________________________________________________

 City:_______________________________________  State:____________   Zip:__________________

 Home Phone______________________________  Cell Phone:________________________________

 Medical, Physical or Other Concerns:_____________________________________________________

We, the staff at Triplett and Propst Performing Arts Studio, LLC recognize our obligation to make sure our students and their parents are aware of the risks and hazards involved in the sport of dance and tumbling.  By signing this waiver, you release Triplett and Propst Performing Arts Studio, LLC and all its employees from all claims on account of any injury which may be sustained by your child while attending any dance class, event associated with Triplett and Propst or outside performance.  You also affirm you now have and will continue to carry proper primary medical, health, hospitalization and accident insurance which you consider adequate for the protection of your child.

Parent Signature:_____________________________________________________  Date:__________