Parental Consent Form Male or Female (circle one)
Name of Dancer:_____________________________Telephone:_______________________________________
Address: ____________________________________________________________Postal Code: ____________
Date of Birth: _______________________ Age_______________ Grade level for the current school year:_____
Mother’s Name: _____________________ Mother’s Work Number: _____________ Cell___________________
Father’s Name: ______________________ Father’s Work Number: ______________Cell___________________
Student resides with: __________________________________________________________________________
EMERGENCY CONTACT INFORMATION
In an event the parents cannot be reached regarding any situations or emergencies any Volunteerr or employee of
True Blessing or Young Starz will contact the following person(s) on behalf of the member:
Name:____________________________ Relationship:_______________ Phone:_______________________________________ Name:____________________________ Relationship:_______________ Phone:_______________________________________
Please list any medical/physical concerns that the Dance staff should be made aware of:
PARENTAL CONSENT FOR PARTICIPATION
We hereby consent for ____________________________________________________ to participate in the Young Starz Dance Activities, Practices, Workshops, and Competition (Local and Out of Town): I understand that exercises and acute dance techniques can result in minor or serious injuries. I also understand that all safety precautions do not exclude dancer from expected or unexpected injuries.
As a Young Starz Dance member or parent, I waive and release all rights and claims against True Blessings/Young Starz Dance/Freedom Dance Center, members, staff, sponsors, agents, representatives, and anyone connected through contracted services. I HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING IN ANY/ALL ACTIVITIES ASSOCIATED WITH True Blessings/Young Starz Dance/Freedom Dance Center, CascadiaNow!/Girl Scouts Troop #46985 including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability without fault.
I certify that I am physically fit, have sufficiently prepared or trained for participation in this activity, and have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems which preclude my participation in this activity.
I acknowledge that this Accident Waiver and Release of Liability Form will be used by the event holders, sponsors, and organizers of the activity in which I may participate, and that it will govern my actions and responsibilities at said activity.
In consideration of my application and permitting me to participate in this activity, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows: (A) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this activity, THE FOLLOWING ENTITIES OR PERSONS: True Blessing/ Young Starz Dance /Freedom Dance Center, CascadiaNow!/Girl Scouts Troop #46985 and/or their directors, officers, employees, volunteers, representatives, and agents, and the activity holders, sponsors, and volunteers; (B) INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE True Blessings/Young Starz Dance, CascadiaNow!/Girl Scouts Troop #46985 The entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this activity, whether caused by the negligence of release or otherwise.
I acknowledge that True Blessings/Young Starz Dance/ Freedom Dance Center/CascadiaNow!/Girl Scouts Troop #46985 and their directors, officers, volunteers, representatives, and agents are NOT responsible for the errors, omissions, acts, or failures to act of any party or entity conducting a specific activity on their behalf.
I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during this activity.
I understand while participating in this activity, I may be photographed. I agree to allow my photo, video, or film likeness to be used for any legitimate purpose by the activity holders, producers, sponsors, organizers, and assigns.
The Accident Waiver and Release of Liability Form shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.
I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT OF MY OWN FREE WILL.
Signature(s) of Parent(s) or Guardians(s) Date Email Address
Young Starz Income Guidelines (Annually)
Tuition is due before the second Saturday of each month. All parents have a financial responsibility to make all tuition payments on time. Payments not secured by the second Saturday of each month will now result in a $5 late fee. Any youth with a negative account balance will not be able to return to the program or participate in any YSDC/GS events held by Young Starz, until the account is paid in full. Payments can be made in person to Marzella or Amber or online @ https://www.trueblessingsnpo.org/young-starz/
Please let our staff know if there is any financial hardship (payment plans may be available).
*All youth are encouraged to show up on time and participate in the program every Saturday.
*Each youth will now receive a coin or stamp for being on time and/or for their participation in class. These coins will be able to be used at the pop-up shop created just for YS members.
*Starting March 10, 2018, 3 or more missed program classes will jeopardize any YS member spot in the program or invitation to future events.
$0 - $8,500
Tuition Rate $10 per month
$8,500 - $16,500
Tuition rate $15 per month
$16,500 - 24,500
Tuition rate $20 per month
$24,500 - $32,500
Tuition rate $25 per month
$32,500 - $45,000+
Tuition rate $30 per month
Office Use Only
Reg. pd: _________________________________________Enrolled in: ___________________________
YSDCWear rcvd: __________Date began class: _________Monthly rate: __________________________
⬜Ck #____________ ⬜Credit Card_____________ ⬜Cash recpt # ______________________________
True Blessing/Young Starz