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Azarov Ballroom Inc.

d/b/a Fred Astaire Franchised Dance Studio

1900 OKEECHOBEE BLVD. SUITE A2

WEST PALM BEACH, FL 33409

Fred Astaire Dance Studio is registered with the State of FL as

a Ballroom Dance Studio. REGISTRATION NO. DS709

   I hereby state that I am an employee/student at a Fred Astaire Franchised Dance Studios - West Palm Beach, and as such participate in the teaching or taking of dance instruction and/or other dance studio activities such as parties, travel, dance competitions and dance vacation type trips.

   I fully understand and acknowledge that there are risks and dangers associated with participation in dance events and activities which could result in bodily injury. These risks and dangers, including communicable diseases, may be caused by my action, inaction or negligence, or the action, inaction or negligence of others. There may be other risks that are not known or that are not reasonably foreseeable at this time. I accept and assume all such risks and responsibility for any losses and/or damages following any injury, however caused and whether caused in whole or in part by the negligence of the Releasees named below. I acknowledge that Azarov Ballroom Inc. d/b/a Fred Astaire Dance Studios - West Palm Beach (herein after referred to as the STUDIO) will not render any medical services including medical diagnosis of any physical condition. I affirm that I am in good health and suffer no physical impairment that could limit my use of the facilities of the STUDIO. I HEREBY RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE Azarov Ballroom Inc. d/b/a Fred Astaire Dance Studios - West Palm Beach, as well as it's owners, and any of the instructors at the STUDIO on behalf of myself or any person claiming on my behalf . I specifically agree that the STUDIO, its officers, members, employees, agents and legal representatives, whether acting in their business or individual capacities, and their successors and assigns (each a "Releasee" and collectively the "Releasees") shall not be liable for any claim, demand, or cause of action of any kind whatsoever for, or on account of death, personal injury, property damage or loss of any kind resulting from or related to my use of the STUDIO'S facilities or my participation in any dancing, or exercise or activity within or without the STUDIO'S premises, whether it be in another city, state or country, and for whatever period said activities may continue, and I agree to hold the Releasees harmless for same.

First Students Name

First Name*

Middle Name

Last Name*

Phone*
First Students Date of Birth*
First Students Signature*
Second Students Name

First Name*

Middle Name

Last Name*
Second Students Date of Birth*
Third Students Name

First Name*

Middle Name

Last Name*
Third Students Date of Birth*
Fourth Students Name

First Name*

Middle Name

Last Name*
Fourth Students Date of Birth*
Fifth Students Name

First Name*

Middle Name

Last Name*
Fifth Students Date of Birth*
Sixth Students Name

First Name*

Middle Name

Last Name*
Sixth Students Date of Birth*
Seventh Students Name

First Name*

Middle Name

Last Name*
Seventh Students Date of Birth*
Eighth Students Name

First Name*

Middle Name

Last Name*
Eighth Students Date of Birth*
Ninth Students Name

First Name*

Middle Name

Last Name*
Ninth Students Date of Birth*
Tenth Students Name

First Name*

Middle Name

Last Name*
Tenth Students Date of Birth*
Students Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
COVID 19 Guest Screening Questionnaire In Person. Fred Astaire Dance Studios® is committed to providing a safe workplace and reducing the risk of injury and harm to all employees, sub-contractors, clients, visitors and the general public and is following the development of the Coronavirus disease (COVID-19) closely. In the interest of maintaining a safe and healthy environment for everyone, we ask that you carefully complete the self-assessment.
Have you traveled to any foreign countries in the last 14 days?*
No
Yes
. Do you have a Fever and any of these symptoms: Cough, sore throat, or difficulty breathing?*
No
Yes
WHAT TO DO NEXT

• If you have answered YES to any question: We advise you not to take an in-person lesson and to schedule a virtual lesson instead.

• If you answer NO to all the above: thank you for being with us today. 

By signing below, I declare that I have truthfully answered the questions. I agree to all Terms and Conditions of the waiver of liability and indemnity agreement.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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