CANADA’S BALLET JÖRGEN GEORGE BROWN JUNIOR COMPANY PROGRAM 2022 PERSONAL INFORMATION & EMERGENCY CONTACT INFORMATION

Select Your Program*

4 Weeks
6 Weeks

Student Information

Your Legal Name in Full*

First Middle Last

Date of Birth*

Gender*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone Number*

Mobile Number

Primary Email Address*

Do you have any allergies, if so please list them below.*

Injuries

Do you have any or have you incurred any recent injuries?*

Yes
No

If yes - please list:

During Program Emergency Contact

Emergency Contact Name*

First Last

Phone Number*

Waiver of Liability & Policy Consent

Student Name*

First Last

Waiver of Liability Consent (required)*

I agree to Jörgen Dance's Waiver of Liability

In Consideration of Jörgen Dance accepting the Student into the 2022-23 Junior Company Program, the undersigned hereby waives any claims to which undersigned may become entitled for injury or damage and releases Jörgen Dance, its employees, officers and directors and teachers in the Program, from any claims for injury or damage the Student may suffer or incur while participating in the Program.

Appropriate Physical Contact in Dance Policy (required)*

I have read and understood Jörgen Dance's Appropriate Physical Contact in Dance Policy

Please view the policy at the top of this page.

Jörgen Dance & George Brown Dance Photograph and Electronic Media Release Form (optional)

I agree to Jörgen Dance & George Brown Dance Photograph and Electronic Media Release Form

I/We [Student/Parent/Legal Guardian listed above] hereby irrevocable grant to Jörgen Dance & George Brown Dance the non-exclusive right to use and incorporate, along or together with other materials, in whole or in part, screen shots or screen recordings taken of [Student Name listed above] as a Result of my participation in Ballet Jörgen & George Brown Dance. I/We agree that these MATERIALS will be the exclusive property of Jörgen Dance & George Brown Dance, and that all reproduction rights are handed over to Jörgen Dance & George Brown dance to use the MATERIALS in such medium as brochures, flyers, poster, web sites in perpetuity.

Those who do not wish to be recorded or photographed during virtual Zoom classes will turn off their camera when notified of a screen shot or screen recording.

I/We understand that in signing this release in duplicate that there will be no compensation or remuneration for the use of these MATERIALS and there is no guarantee that they will be use.

I am:

18 years of age or older as of today's date.
The Parent(s)/Guardian(s) of [Student Name as listed abov] and can therefore legally act on her/his behalf.

Today's Date

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CANADA’S BALLET JÖRGEN GEORGE BROWN JUNIOR COMPANY PROGRAM 2022 PERSONAL INFORMATION & EMERGENCY CONTACT INFORMATION

Canada’s Ballet Jörgen & George Brown Dance Junior Company Program 2022 – Personal Information & Emergency Contact Information

Student Information

Injuries

During Program Emergency Contact

Waiver of Liability & Policy Consent

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