4th of July Celebration Waiver

Name of registered dancer(s) in your party

1.
2.
3.
4.
5.

_____________________________
_____________________________
_____________________________
_____________________________
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Doctors
Office:____________________________________________________________
Doctors Office Contact:(_____)_____-_____
Doctors Cell Phone:(_____)-_____-_____
Emergency Contact:(_____)_____-_____
(_____)_____-_____
Allergies:______________________________________________________________
________________________________________________________________________
______________
**Child may get hit or burnt by fire. If so, child will be taken into an
ambulance if severe or treated with ice. There will be nuts and dairy at
this event so watch what your child eats. If allergy attack takes place,
child will be given medication if parents has(such as epi-pen) or taken
into an ambulance with coach chosen by child and parent(s).
Parent/Guardian Name(s)
1. _____________________________________________________________
2. _____________________________________________________________
Parent Guardian(s) Signature:
X____________________________________________
X____________________________________________