The Maine Dance Academy 2011-2012
Home Phone:___________________________ Cell Phone:______________________
Age:_______________ Grade in School:______________ TMDA Member?_________
WARNING OF RISK TO PARTICIPANT:The Maine Dance Academy (TMDA) is not responsible for providing medical
accidental injury insurance on students. Parents/guardians are required to provide adequate accidental and medical insurance
for their child enrolled in TMDA. My child and I are aware that participation in all TMDA gymnastic/tumbling classes is
potentially hazardous and may involve risk of injury. TMDA, Colleen DuPlissie, the teachers, the assistants, the secretaries
and the owner of the property at 15 Sweden Street, Caribou, ME shall not be held responsible for treatment, injury or
losses related to TMDA. Neither Colleen DuPlissie, nor any teacher, nor the studio, nor the owners of said property are
liable for the loss or damage to personal property. As a parent, guardian, and/or participant, I am aware of the hazards and
my ability or my childs ability to participate. Each student may decline to participate in any activity but only with written
permission of a parent or guardian. Please inform the teachers of any physical limitations or conditions. I hereby, for myself,
my heirs, executors and administrative waive and release all rights and claims against The Maine Dance Academy, its
employees, volunteers and owners from all losses, injury, damages, fees and other expenses arising out of, or in connection
with all our participation at The Maine Dance Academy. I have also read the entire rules and regulations posted on TMDA’s
website and will adhere to them accordingly. You indicate your agreement by entering your name below. All losses suffered
while participating in gymnastics/tumbling at TMDA are the sole responsibility of the client entering his/her name below and
you will not hold TMDA liable for anything.
Parent Signature:___________________________________________________ Date:________________________
I am also aware that at various points during the dance year, TMDA will be sharing pictures of their dancers on their
website .I recognize that TMDA may post pictures (not names) of myself and/or my child on their website. I hereby consent
for myself and/or my children to have their pictures put on the website at www.themainedanceacademy.com.
Gymnastic Registration Fee: $30.00 Class Fees: 1 hour = $100.00 per semester 1.5 hours = $150.00 per semester
Mail form and registration fee to: Colleen DuPlisse, 82 Solar Drive, Caribou, ME 04736 Registrations due August 17, 2011!