Release and Authorization

Name of Student:  ________________________________________________________

Indicated in the space below are any health problems or conditions of which Steps of Faith Dance Studio should be aware (such as heart, back, medical, allergy, muscular, diabetes, epilepsy, chemical or neurological condition, special medication, knee, kidney, shoulder problems, etc.)

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I understand that risk of injury is inherent in any physical activity and I, on behalf of myself and my child, knowingly and voluntarily accept that risk.  I, the undersigned, for myself, my heirs, administrators, and executors, hereby waive and release Julie R. Bridges individually and Julie R. Bridges L.L.C. (and Steps of Faith Dance Studio) and staff from any and all claims or damages of any kind arising out of my participation or my child’s participation in the classes Steps of Faith Dance Studio.  I further certify that the afore mentioned student is in proper physical condition to participate in the dance/cheerleading/tumbling program and that she/he has been examined by a licensed physician and found to be in proper physical condition to participate in said program.

I, the undersigned, do hereby authorize Julie Bridges or her designated agents (being teachers employed by Steps of Faith Dance Studio) to obtain medical treatment for my said child in emergency situations where I can not be reached in time to authorize the treating physician to provide such emergency medical services.  This authority includes the power to authorize any and all treatment deemed necessary under the circumstances by a licensed physician.  

Signature of Parent/Guardian ______________________________Date:_____________

Optional Information

Physician:  ______________________________________________________________

Hospital Preference: _______________________________________________________

Insurance Company and Policy Number:  ______________________________________

Allergies to Medications:  __________________________________________________

Additional Information/Comments: ___________________________________________