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4. SIGN UP SHEET FOR ADULT PROGRAMS

   (All class fees are paid at the door on the day of the class.)

   
   

   
   

6. Name
7. Phone Number
9. Address
11. City
12. State
13. Zip Code
15. Program:
    -- Select One --Ultimate Line DanceZumba Latin Dance

17. Waiver of Liability and Release

19. I, the undersigned participant, acknowledge that my participation in the City of [City Name]'s Adult Dance Class involves physical activity that may result in personal injury, illness, or property damage. I understand that my participation is voluntary and at my own risk.

    In consideration of being allowed to participate in this program, I hereby release, waive, discharge, and covenant not to sue the City of [City Name], its officers, agents, employees, volunteers, or other participants from any and all liability, claims, demands, actions, or causes of action arising out of or related to any loss, damage, or injury, including death, that may be sustained by me or to any property belonging to me, whether caused by the negligence of the City or otherwise, while participating in the program or while on city property.

    I understand and agree that the City of [City Name] does not provide health or accident insurance and that I am solely responsible for obtaining coverage.

    I certify that I am physically fit and able to participate in the dance class and that I have no known medical conditions that would prevent my participation.

21. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
23. Electronic Signature
24. Date
    Date

    Date
29. Emergency Contact Name:
30. Phone Number:
32. Relationship:
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field