San Pedro Ballet School

1231 S. PACIFIC AVENUE • SAN PEDRO, CA 90731 • (310) 732-1861 • www.sanpedroballetschool.com

Student Information and Release of Liability

Billing Name

Address City Zip

E-Mail Home Phone

Parent 1 Phone

Parent 2 Phone

Doctor: Phone

List any conditions which should be known by a physician administering treatment:

Emergency contact:

Name Phone

STUDENT’S NAME______________________________________ DOB _________________________

RELEASE OF LIABILITY

In the event of an accident, injury, or illness of the above named participant, consent is hereby given to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care which is deemed advisable by and is to be rendered under the general supervision of any physician and surgeon licensed under the provisions of the medicine practice act of the medical staff or employed by the director of the emergency department of the hospital. I release the San Pedro Ballet School and its elected representatives and employees from any and all claims, demands, liability, or loss which may arise as a result of participation in the selected activity.

I absolve and hold harmless the San Pedro Ballet School and its employees and contract instructors from any liability, which may result from my participation or that from any minor in my legal custody, in the selected activity. If the participant is a minor, I also give my permission for his/her participation at the San Pedro Ballet School and for any necessary medical treatment.

I have read and understand the above, as well as San Pedro Ballet School’s Rules and Policies.

Parent or Guardian Date

Class	Day	Time	Class	Day	Time