Dual Star Academy of Dance - Pom Prep/Mock Audition Clinic 2023 REGISTRATION FORMStudent's Name* First Last High School Team Student is trying out for* Current Grade* Student Age* Are you a current student at Dual Star?* Yes No Used to be Which Clinic are you registering for?* Select All Sunday, January 22, 2023 (Coach Mary Kate) Saturday, February 25, 2023 (Coach Alex) Parent Name* First Last Email* Phone*Payment Information$35 if only taking one clinic $60 if taking bothHow would you like to pay?*Credit Card on File (current Dual Star students only)Credit Card - Create a secure account O(non Dual Star student)CashCheckPlease Provide the total amount you will be paying* Create a new account for secure payment Dancers who do not already have an account with us please use this link to create one: https://app.akadadance.com/customer/login?schoolId=ak600645jCredit Card Authorization* I authorize Dual Star Academy of Dance to charge the card listed above Consent* I agree to the following COVID-19, Medical and Injury AgreementCOVID-19 LIABILITY WAIVER AND AGREEMENT: I acknowledge the contagious nature of COVID-19 and other contagious diseases and viruses and voluntarily assume the risk that I and/or my children may be exposed to or infected by COVID-19 by attending and participating and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand the risk of becoming exposed to or infected by COVID-19 and other contagious diseases and viruses may result from the actions, omissions, or negligence of myself and others, including, but not limited to, employees, volunteers, and program participants and their families. I agree that my child(children) do not currently, nor have had in the last two weeks a fever, cold, vomiting, diarrhea, cough, sore throat, chills, muscle pain, fatigue, shortness of breath and/or loss of taste or smell. To the best of my knowledge, I affirm that I, as well as those living in my household, have not been diagnosed with COVID-19 or knowingly been exposed to anyone diagnosed with COVID-19 within the last 14 days. If I, or anyone else, I have knowingly been exposed to is diagnosed with COVID-19, I will only return to Dual Star Academy of Dance after 14 days without symptoms and/or being cleared of COVID-19 by a doctor. Until further notice, anyone ages 11+ is required to wear a mask at all times while in the building. Medical Agreement I understand that dancing is a strenuous physical activity. To my knowledge, my child has no medical problems or injuries that would prevent participation in class. I understand that it is my responsibility to inform a physician of any medical issues and to obtain written consent for participation. I agree to inform the instructor(s) of any known health condition that may affect class participation. Injury Agreement I agree to release Dual Star Academy of Dance and its participants, or any instructor from liability related to accidents or injury. I also agree to communicate in the event of an injury and understand that physical clearance from a doctor may be required to return to participating in class. Δ
