| Registration Form |
Date ___________________
Student Name __________________________Age _________Grade ______
Parent/ Name_______________________________________________
Address___________________________________________________
City, State & Zip___________________________________________
Phone_____________________________________________________
Email_____________________________________________________
Class 1__________________ Class 2 __________________________
Shirt Size ________ Skirt Size _________ Pants Size __________
How did you hear about Journey?______________________________
Special Education Y N
Food Allergies ___________________________________________________________
Medical Conditions/Considerations___________________________________________
Emergency Contact _______________________________________________________
Authorized alternate pick-up
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
By signing below, I am indicating that I have read and understand the JPAC/JAS Policies & Procedures for the current
semester. I am aware of all payments and fees associated with this registration and agree to all of the terms and
conditions. I understand that by registering for Studio classes that I am responsible for tuition for the entire session
regardless of absence.
_____________________________ _______________________________________________
Parent/Guardian Name Parent/Guardian Signature & Date
Office Use Only
Payment Option ____________________________ Tuition Rate__________________________________
Release, Waiver of Liability & Indemnity Agreement
In consideration of being permitted to participate in any way in the Journey Performing Arts Center and Journey After
School Programs and/or being permitted to enter for any purpose any restricted area (here in defined as any area
where in admittance to the general public is prohibited), the parent(s) and/or legal guardians) of the minor participant
named below agree:
I understand that I have the option inspecting all facilities related to the program.
I/WE fully understand and acknowledge that
(a) There an: risks and dangers associated with participation in Dance events and activities which could result in
bodily injury partial and/or total disability, paralysis and death.
(b) The social and economic losses and/or damages, which could result from these risks and dangers described
above, could be ~.
(c) These risks and dangers may be caused by the action, inaction or negligence of the participant or the action.
inaction or negligence of others, including, but not limited to, the Releases named below.
(d) There may be other risks not known to us or an: not reasonably foreseeable at his time.
I/WE accept such risks and responsibility for the losses and/or damages following such injury, disability, paralysis or
death, caused, whether caused in whole or in part by the negligence of the Releases named below.
I/WE HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE the dance facility, company used by
the participant, including its owners, managers, promoters, lessees of premises used to conduct the dance event or
program, premises and event inspectors, underwriters, consultants and others who give recommendations,
directions, or instructions to engage in risk evaluation or loss control activities regarding the dance facility or events
held at such facility and each of them, their directors, officers, agents, employees, all for the purposes herein referred
to as "Release" ... FROM ALL LIABILITY TO THE UNDERSIGNED, my/our personal representatives, assigns,
executors, heir's and next to kin FOR ANY AND ALL CLAIMS, DEMANDS. LOSSES OR DAMAGES AND ANY CLAIMS
OR DEMANDS THEREFORE ON ACCOUNT OF ANY INJURY, INCLUDING BUT NOT LIMITED TO THE DEATH OF
TIHE PARTICIPANT OR DAMAGE TO PROPERTY, ARISING OUT OF OR RELATING TO THE EVENT(S) CAUSED OR
ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE RELEASEE OR OI'HERWISE.
Minor Photo Release
In consideration of the minor named below as a student of Journey Performing Arts Center/ Journey After School, and
for other good and valuable consideration herein acknowledged as received, upon the terms hereinafter stated, I
hereby grant to Journey Performing Arts Center, Inc , and those acting with its authority and permission, the absolute
right and permission to copyright and use, re-use, publish, and re-publish
photographic portraits, pictures, or videos of the minor or in which the minor may be included, in whole or in part, in
conjunction with the minor's own or a fictitious name, or reproductions thereof in color or otherwise, made through
any medium at his/her studios or elsewhere, and in any and all media now or hereafter known, for art, advertising
trade or any other purpose whatsoever. I also consent to the use of any printed matter in conjunction therewith,
including but not limited to flyers, website, newspaper, ect.
I hereby waive any right to compensation or the right to final inspection of printed materials that may be used in
connection therewith.
I hereby warrant that I am of full age and have every right to contract for the minor in the above regard.
I HAVE READ THIS PHOTO RELEASE AND WAIVER OF LIABILITY, ASSUMPTI0N OF RISK AND INDEMNITY
AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP RIGHTS BY SIGNING IT,
AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE
BEING MADE TO ME AND INTEND MY SIGNATURE TO BE COMPLETE AND UNCONDITIONAL RELEASE OF ALL
LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW.
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Student Name
_________________________________________
_______________________________________________
Parent/Guardian Name Parent/Guardian Signature & Date