Dance for Parkinson's Registration Form 2018 - 2019 Dance for Parkinson's Registration FormName First Last Email Address Enter Email Confirm Email PhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Partners are welcome! Please provide the name of your partner if they will regularly attend class with you. First Last Partner Email Enter Email Confirm Email Accommodations / additional information you would like to share:Do you participate in any other movement classes or activities? Please describe.Emergency Contact Name / Phone:Cost$5 per class - your first class is free! Payable on a walk-in basis. Partners participate at no charge.Release and Waiver of LiabilityPlease read and check Yes or No below.*I recognize the risks of accident or injuries associated with any program of dance and acknowledge that I am participating upon the express understanding that I am willing and able to accept full responsibility for my own safety and welfare. I hereby release PBT/PBT School and agree to hold PBT/PBT School harmless from and against any and all claims and liabilities whatsoever which I may have, arising out of the participation with PBT/PBT School, except for those relating from gross negligence or willful misconduct of PBT/PBT School. I hereby execute and deliver this release to induce PBT School to permit me to participate in its programs. In teaching the art of ballet, it is appropriate for a teacher to put their hands on a student to correct the student’s posture, physical line or positioning of the student’s body, or to help a student hold a position. PBT School does not tolerate harmful or inappropriate teacher-student interaction. I assume the risk associated with dance instruction / classes and agree that the PBT School, PBT and its Board of Trustees, faculty and volunteers shall not be liable in any way for any injuries sustained or loss of property while attending PBT School or any of its related functions. Release and Waiver of Liability - Yes Media ReleasePlease read check Yes or No below. I do hereby give, grant and assign to Pittsburgh Ballet Theatre, Inc., and its assigns, licensees and legal representatives (“PBT”) the right, consent and permission to use, publish, copy, reproduce, create digitized images of, adapt, distribute, transmit, broadcast, display, modify and otherwise make use of my (or my minor child, as appropriate) appearance, likeness and form in all forms of media and in all manner now known or hereafter to become known, including electronic media and/or composite representations, for advertising, trade, or any other lawful purpose. PBT shall have the right to exercise such rights with my appearance, likeness and form alone, or with other materials, including, but not limited to, text, data, images, photographs, illustrations, animation, graphics, and video or audio segments of any nature. The rights granted to PBT hereunder are world-wide, irrevocable, perpetual, and assignable. I hereby waive all rights and release PBT and its directors, officers, employees, agents, and independent contractors from, and shall neither sue nor bring any proceeding against any such parties for, any liability, loss, demands, claims, damages or causes of action, whether now known or unknown, for defamation, invasion of right to privacy, publicity or personality or any similar matter, or based upon or relating to the use and exploitation of my appearance, likeness and form. Media Release - Yes Media Release - No Additional InformationUse of Contact InformationBy completing this form, I grant PBT permission to use my personal information to contact me about upcoming events and promotions. PBT will not rent, sell, or share personal information with third-party companies or organizations unless permission is received. Yes No Please let us know how you heard about the class:CommentsThis field is for validation purposes and should be left unchanged.