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Petite Fleur Summer 2018 registration


Please fill out the registration form below. This information will be your official registration for the Fleur-De-Lis Academy Petite Fleur Summer Camp 2018.

Student Name *
Student Name
Student Address *
Student Address
Parent/Guardian Name *
Parent/Guardian Name
Parent/Guardian Phone *
Parent/Guardian Phone
Parent/Guardian Address *
Parent/Guardian Address
Let us know what dance experience your child has had, if any.
Emergency Contact *
Emergency Contact
Emergency Contact Phone *
Emergency Contact Phone
How did you find Fleur? *
Check all that apply.
Please let us know of any food or drug allergies, current or past physical or mental medical conditions or injuries that Fleur-De-Lis staff need to be aware of.
As the legal parent or guardian I authorize Fleur-De-Lis Academy LLC to obtain emergency treatment for my minor child by an appropriate healthcare professional should the need arise while attending the program. Type Parent/Guardian Name:
Upon receipt of this registration form you will receive via email an invoice for the deposit. The $75 non-refundable deposit is due by April 9, 2018. The balance of $125 is due by June 10th. You will receive an invoice for the balance due via email. All invoices come from SQUARE, our payment software. If you wish to make 2 monthly payments, please indicate below. Save your card info to your Square account with the deposit invoice. The balance due payment(s) will then be automatically charged to your card on file on the 5th of the month(s) following the deposit payment date.
If there is anything you want to be sure we know that is not covered elsewhere in this form, or a question you have, please fill out this section.
I, the undersigned, give permission for my Child to participate in the FDLA Academy Summer Camp, offered on behalf of the Fleur-De-Lis Academy (“FDLA”), at the Mellwood Art Center from June 18- June 22, 2018. In consideration for my Child’s participation, I, on behalf of my Child, agree to the following: I understand the Program consists of the following activities: dancing, consumption of food and beverages, optional recreational activities, and otherwise being present on FDLA’s campus for the duration of the Program. I understand that as part of my Child’s participation in the Program there are dangers, hazards, and inherent risks to which my Child may be exposed, including, but not limited to, the risk of serious physical injury, temporary or permanent disability, and even death, as well as economic and property loss. I further understand that participating in the Program may involve other risks and dangers, whether known or unknown nor reasonably foreseeable, including the following: ballet-specific injury (e.g., toe, foot, or leg injuries), food/drink allergies, sprains, cuts, bruises, fire, drowning, or other emergency on the FDLA campus. I fully understand the scope of the activities and the risks involved. I voluntarily accept and assume all risks of injury, loss of life, or damage to property arising out of my Child’s participation in the Program. I hereby release and fully discharge FDLA, including its officers, employees, and agents, from any and all claims or causes of action, including all liability for damage to personal property or personal injury which may result from my Child’s participation in the Program, that may be brought by me or my Child or for any injury or loss that my Child may suffer while participating in the Event, whether caused by negligence or otherwise, to the fullest extent permitted by law. I further release, indemnify, and hold harmless FDLA, including its officers, employees, and agents, from and against any and all liability, actions, debts, claims, and demands of every kind whatsoever, including, but not limited to, any claim for negligence and/or any present or future claim, loss, or liability for which my Child may be liable to any other person or to FDLA that arises out of my Child’s participation in the Program. In the event of an accident or serious illness, I hereby authorize representatives of FDLA to obtain medical treatment and transport for my Child on my behalf. I waive my right to receive informed consent prior to such transportation or treatment. I hereby hold harmless and agree to indemnify FDLA from any claims, causes of action, damages and/or liabilities, arising out of or resulting from the medical treatment or transport. I further agree to accept full responsibility for any and all expenses, including medical expenses that may derive from any injuries to my Child that may occur during her/his participation in the Program. This Agreement shall be governed by and construed under the laws of Kentucky. Notwithstanding any other agreement that I have signed related to this Program that purports to establish the venue for any litigation arising from this Program, I agree that I will file no action against the Fleur-De-Lis Academy or its officers, employees, and agents, whether based on this Agreement or in any way otherwise connected to this Program, in any court other than the Circuit Court of Jefferson County, Kentucky. I understand and agree to all of the terms of this Agreement. I understand that I am giving up substantial rights (including the right to sue) and acknowledge that I am willingly signing this document. My signature on this document is intended to bind not only myself and my Child, but also the successors, heirs, representatives, administrators, and assigns of myself and my Child. TYPE NAME AND DATE BELOW. My typed name is in lieu of a physical signature, and legally binding.