Registration

spring 2022

Please note immediately below the registration form includes schedules for both evening classes and after school programs, as well as some important notes and schedule of fees.

Spring 2022 REGISTRATION

* Indicates required field

Name *

First

Last

Guardian Name *

First

Last

Grade *

Age *

Email *

Phone *

Emergency Contact Phone *

Phone (Alternate) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Choose Classes *

Afterschool at Fallsmead Afterschool at CGES

Please contact the JCC directly for classes at their location.

For Wayside, Bayard, Farmland, and Beverly Farms please register at www.kiddo.us.

All evening classes are full at this time.
Please contact Angie Caulfield at rockvilledancing@gmail.com for more details.

Medical Concerns *

Terms and Conditions

I give permission for my child, who is listed on this registration form, to participate in dance classes taught by ACD Dance Company, LLC. I understand that dance can be dangerous. I accept that any activity involving motion can cause serious injury. My child has had a medical examination within the last twelve months and is physically, mentally and emotionally capable in participating in the sport of dance. I agree to be responsible for any medical bills incurred resulting from illness or injury while my child is participating in dance classes with ACD Dance Company, LLC. In the event of injury or illness, every effort will be made to contact parents or guardian. If necessary, I authorize agents of ACD Dance Company, LLC to administer first aid and or/authorize medical treatment. While my child is participating in online classes with ACD, I will provide a safe dance environment for him/her. I will not hold ACD Dance Company, LLC or Angie Caulfield responsible for any risks, injury, accident, or damage, known or unknown, which may incur as a result of my child participating in dance classes in person or online. I also agree to permit Angie Caulfield and ACD Dance Company, LLC to use pictures and the likeness of my child for use to promote ACD Dance Company, LLC on the dance website and promotional materials. I understand that I may revoke my consent for continued use of my child’s pictures and likeness at any time. I confirm that I am 18 years or older and can legally act as a representative on behalf of said child. I also understand that registration is not complete without payment.

COVID RELEASE FORM

COVID-19 Liability Release Waiver: The World Health Organization has declared the novel Coronavirus (COVID-19) a worldwide pandemic. Due to its capacity to transmit from person-to-person through respiratory droplets, the government has set recommendations, guidelines, and some prohibitions to which we adhere. In consideration of my participation in the foregoing, the undersigned acknowledge and agree to the following: • I am aware of the existence of the risk on my physical appearance to the venue and my participation to the activity of a dance class that may cause injury or illness such as, but not limited to Influenza, MRSA, or COVID-19 that may lead to paralysis or death. I have not experienced symptoms that of fever, fatigue, difficulty in breathing, or dry cough or exhibiting any other symptoms relating to COVID-19 or any communicable disease within the last 14 days. I have not, nor any member(s) of my household, traveled by sea or by air, internationally within the past 30 days. I did not, nor any member of my household, visit any any area within the United States that was reported to be highly affected by COVID-19, in the last 30 days . I have not been, nor any member(s) of my household, diagnosed to be infected of COVID-19 virus within the last 30 days. Following the pronouncements above I hereby declare the following: • I am fully and personally responsible for my and my child’s safety and actions while and during may participation and I recognize that I may be in any case be at risk of contracting COVID-19.With full knowledge of the risks involved, I hereby release, waive, discharge ACD Dance Company, LLC and Angie Caulfield, instructors, its board, officers, independent contractors, affiliates, employees, representatives, successors, and assigns from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by me related to COVID-19 while participating in any activity while in, on, or around the premises located at 1119 Nelson Street, Rockville, MD 20850 or while using the facilities that may lead to unintentional exposure or harm due to COVID-19.I agree to indemnify, defend, and hold harmless ACD Dance Company, LLC and Angie Caulfield from and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against any of the released party due to injury, loss, or death from or related to COVID-19. By signing below I acknowledge that I have read the foregoing Liability Release Waiver and understand its contents; that I am at least eighteen (18) years old and fully competent to give my consent on my behalf and that of my child; that I have been sufficiently informed of the risks involved and give my voluntary consent in signing it as my own free act and deed; that I give my voluntary consent in signing this Liability Release Waiver as my own free act and deed with full intention to be bound by the same, and free from any inducement or representation. This waiver will remain effective until laws and mandates relevant to COVID-19 are lifted.

I agree that electronic submission constitutes signature, and in doing so, I acknowledge and represent that I read and understand both thes terms and conditions and the Covid release form and agree to them voluntarily.

Signature *

Yes, I agree to these terms and conditions.

Submit

Evening Class Schedule

2022 Dates For ACD Dance
File Size:	77 kb
File Type:	doc

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MCPS After School Activities - Spring 2022 Flyers

Fallsmead
File Size:	75 kb
File Type:	doc

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Beverly Farms
File Size:	75 kb
File Type:	doc

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JCC
File Size:	74 kb
File Type:	doc

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Bayard
File Size:	76 kb
File Type:	doc

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CGES
File Size:	76 kb
File Type:	doc

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Farmland
File Size:	75 kb
File Type:	doc

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Wayside
File Size:	76 kb
File Type:	doc

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