Bridges Registration Form 2021/22
We're so excited to see you for Bridges this year.
If you have any questions, please contact email@example.com.
Please note that asterisks indicate a required field. Thank you!
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Medical and Media Releases
By checking "yes" below on behalf of my child, I assume the risk associated with dance instruction / classes and agree that the Pittsburgh Ballet Theatre School (PBTS), Pittsburgh Ballet Theatre (PBT), and its Board of Directors, Faculty, Staff and Volunteers shall not be liable in any way for any injuries sustained or loss of property while attending PBTS or any of its related functions. I hereby grant permission to the Director and /or staff of PBTS to authorize hospital admission and medical, surgical, and emergency treatment, including blood or blood product, transfusions, and diagnostic procedures. Additionally, I grant permission for the administration of anesthesia for the student where medically necessary in case of emergency, accident, and illness, and only in the case that the parent or Family Physician, listed above, cannot be contacted.
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 (or my minor child, as appropriate) 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 (or my minor child, as appropriate) appearance, likeness and form.
1. I am aware of the highly contagious nature of COVID-19 and the risk that my child(ren) and I may be exposed to or contract COVID-19 while on the premises of and/or participating in classes at the Pittsburgh Ballet Theatre and Pittsburgh Ballet Theatre School (collectively, “PBT”). I understand and acknowledge that being on the premises of and/or participating in classes at PBT may increase my child(ren)’s and my risk of being exposed to or contracting COVID-19 and that PBT cannot prevent my child(ren) and me from being exposed to or contracting COVID-19.
2. I agree that I am personally responsible for the safety of myself and my child(ren) while on the premises of and/or participating in classes at PBT. I agree that my child(ren) and I will comply with all PBT policies and rules, including but not limited to, all policies, guidelines, instructions, and posted signage. My child(ren) and I will not enter the premises of PBT or participate in classes at PBT if either myself, my child(ren), or any other members of our household are experiencing symptoms of COVID-19 (such as cough, shortness of breath, or fever), have a confirmed or suspected case of COVID-19, or have come in contact in the last 14 days with a person who has been confirmed or suspected of having COVID-19. I further agree to provide notice to PBT by emailing PBTSchool@pittsburghballet.org within 24 hours in the event myself, my child(ren), or any other member of our household tests positive for COVID-19.
3. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 while on the premises of and/or participating in classes at PBT and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 may result from the actions, omissions, or negligence of myself, my child(ren), and others, including, but not limited to, PBT employees, volunteers, and others on the premises of and/or participating in classes at PBT. I, on behalf of myself and my child(ren), voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, arising from or related to my child(ren) or me being exposed to or infected by COVID-19 while on the premises of and/or participating in classes at PBT (“Claims”).
4. On behalf of myself and my child(ren), I hereby release, covenant not to sue, discharge, and hold harmless PBT and their owners, officers, directors, employees, agents, representatives, insurers, affiliates, successors and assigns (collectively, the “Releasees”) of and from the Claims, now know or hereinafter known, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of PBT and their employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after being on the premises and/or participating in classes at PBT. I promise, on behalf of myself and my child(ren), not to make or bring any Claims against PBT or any other Releasee and forever release and discharge PBT and all other Releasees from liability under such Claims.
5. This waiver of liability and assumption of the risk agreement constitutes the sole and entire agreement of PBT and me with respect to the subject matter contained herein and supersedes all prior and contemporaneous understandings, agreements, representations, and warranties, both written and oral, with respect to such subject matter. If any term or provision of this agreement is invalid, illegal, or unenforceable in any jurisdiction, such invalidity, illegality, or unenforceability shall not affect any other term or provision of this agreement or invalidate or render unenforceable such term or provision in any other jurisdiction. This agreement is binding on and shall inure to the benefit of PBT and me and our respective successors and assigns. All matters arising out of or related to this waiver of liability and assumption of the risk agreement shall be governed by and construed in accordance with the laws of the Commonwealth of Pennsylvania, without giving effect to any choice of law provisions.
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