Ballroom Release Form

Get participant authorization and liability release before a ballroom dance event or class.

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Full Name

First Name

Last Name

Date of Birth

Email Address

Phone Number

Address

Street Address

City

State / Province

ZIP / Postal Code

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

Relationship

Type of Participation

Experience Level

Are you physically able to participate in dance activities?

Yes No

Any injuries or medical conditions?

Yes No

If yes, please describe

Participant Signature

Sign here

Date

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