Student Name *

First Name

Last Name

Guardian Name *

First Name

Last Name

Emergency Contact Number *

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AGREEMENT: I, the undersigned, hereby forever release, discharge, & acquit MSA EDUCATE, MSA AGENCY and LA ESTABLISHMENT, including all their employees, teachers, and agents, from any and all claims for damages or injuries of any kind, nature or description, resulting from the MSA Kids and Teens Dance Day. This expressly includes, but is not limited to, any injury or damage caused by or resulting from the negligence of MSA EDUCATE, MSA AGENCY or LA ESTABLISHMENT, employees, teachers, agents, etc. I acknowledge the fact that certain types of injuries are common & inherent in dance-related activities. This release includes but is not limited to that type of injury. This release shall be binding upon & inure to the benefit of the parties, their successors, assigns & personal representatives. I understand that all Choreographers, teachers and performers automatically grant permission to MSA EDUCATE to use their photos and videos for advertising and publicity purposes, inclusive of television, internet, videotaping, or film broadcast in connection with promotional campaigns. *

I agree