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Student Name

First Name

Last Name

Birthday and Age

School

Allergies

Past Injuries Surgeries Allergies Etc

Parent Name

First Name

Last Name

Contact Email

Contact Phone

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Address

Class Desired

Class Days Time

Registration Fee $50 12 weeks+ /$25 for shorter sessions

Enter Amount

Tuition

Enter Total Tuition Amount plus Registration Fee

RELEASE OF LIABILITY ETC

RELEASE OF LIABILITY, WAIVER OF CLAIMS, MEDICAL AUTHORIZATION,RULES, ASSUMPTION OF RISKS, AND INDEMNITY AGREEMENT In consideration of being permitted to participate in the above class/camp/workshop or event, I, as participant or the undersigned parent or legal guardian of the named child, agree to the following: 1. ASSUMPTION OF RISK I understand and acknowledge that participation in any activities at or with Empowering Minds LLC may involve physical activities and the presence of other participants, which carry inherent risks including, but not limited to, minor or serious personal injury, property damage, theft, illness, or other unforeseen occurrences. I voluntarily assume all such risks on behalf of my child and/or myself. 2. WAIVER AND RELEASE OF LIABILITY I hereby release, waive, discharge, and hold harmless Empowering Minds LLC, its owners, employees, agents, volunteers, contractors, and affiliates from any and all liability, claims, demands, causes of action, or losses of any kind, including but not limited to those arising from injury, death, theft, property damage, or negligence, whether foreseen or unforeseen, related to my child’s or my own participation in activities. 3. 3. INDEMNIFICATION I agree to indemnify and hold harmless Empowering Minds LLC and all related parties from any claims, damages, losses, or expenses (including attorney’s fees) arising out of or related to my child’s participation in classes/camps/workshops or events, including any claim by a third party arising from my or my child’s actions. 4. 4. MEDICAL AUTHORIZATION In the event of an emergency, I authorize Empowering Minds LLC to seek and obtain medical care for my child or myself, and I agree to be financially responsible for any such care. 5. 5. PERSONAL PROPERTY I acknowledge that Empowering Minds LLC is not responsible for any lost, stolen, or damaged personal items brought to the location, class/workshop/camp or event by my child or myself. 6. 6.BEHAVIOR/RULES I understand that all individuals participating in activities with Empowering Minds LLC are expected to follow rules, show respect to staff and others and demonstrate safe and appropriate behavior at all times. Disruptive, aggressive, or unsafe behavior may result in my or my child's removal from Empowering Minds LLC, without refund. Type I Agree

Checkbox

PHOTO RELEASE I give permission for myself/my child to be photographed or recorded for promotional purposes use in media etc.

I Agree

I Do Not Agree

Signature

By typing my name below, I certify that I am the registering adult student,parent or legal guardian of the child named above, have read this waiver in its entirety, understand it, and voluntarily agree to its terms.

Date

YYYY