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PARENT(S)/GUARDIAN(S) RESIDING WITH CHILD

RELEASE AND AUTHORIZATION

Indicated in the space below are any health problems or conditions of which the teacher should be aware (such as back, medical, allergy, muscular, special medication, knee/kidney/shoulder problems, etc.). I understand that risk of injury is inherent in any physical activity and I, on behalf of myself and my child, knowingly and voluntarily accept that risk. I, the undersigned, for myself, my heirs, administrators, and executors, hereby waive and release Sri Pranava Mudhra Dance Academy and its staff from any and all claims or damages of any kind arising out of my child’s participation in the exercise and/or dance program of Sri Pranava Mudhra Dance Academy. I further certify that the aforementioned student is in proper physical condition to participate in the dance program. I, the undersigned, do hereby authorize Sri Pranava Mudhra Dance Academy to obtain medical treatment for my said child in emergency situations where I cannot be reached in time to authorize the treating physician to provide such emergency medical services. I understand that I am responsible for any medical expenses and that the absence of health insurance does not make Sri Pranava Mudhra Dance Academy responsible for payment of medical expenses. This authority includes the power to authorize any and all treatment deemed necessary under the circumstances by a licensed physician.
EMERGENCY INFORMATION
EMERGENCY INFORMATION
EMERGENCY INFORMATION
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I_________________________________ (Print full name) (Print full name), the Parent or Guardian of _________________________________ (Print child’s full name) hereby grant Sri Pranava Mudhra Dance Academy the right to use my child’s photograph(s), video(s), likeness, and/or testimonial(s) and mine in any company advertisement, brochure, or publications including electronic publications, social media (such as the website and Facebook, etc), or in audio-visual presentations, promotional literature, or in other similar ways. This authorization is continuous and may only be withdrawn by my specific rescission of this authorization in writing. Furthermore, for good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, I forever release and discharge Sri Pranava Mudhra Dance Academy from any claims for compensation or otherwise with respect to the usage of such media and content.

CONFIDENTIALITIES

Parents, guardians and students may not use or transmit Sri Pranava Mudhra Dance Academy material, methodologies or content for any new or existing business venture.
CLASS FEES

* Class fees are due at the first class of each month.

* A $10 late fee will be applied to accounts not paid by the 15th of the month.

* Tuition may be paid by the following methods: cash or check in an envelope.

* Checks should be made payable to “Pramila Hariharan”

*  There is a $5 returned check fee, per check, on all returned checks.

* Tuition remains the same regardless of absences and whether it is a long, five-week month or a short, three-week month. Tuition is per month – not per class!