Dance Student/Performer Liability Release Form

Classes, Workshops, Retreats with Ma*Shuqa Mira Murjan

Studio - 15651 Camino Del Cerro, Los Gatos, CA 95032

And/or in transit to and from dance performance events with Reel Sound and Light Productions

(408) 356-9473  MaShuqaDancer@gmail.com   www.MaShuqa.com

(Please complete all areas)                              Date: ____________________________________

For and in consideration of my engagement as a dance student/performer of Ma*Shuqa Mira Murjan of Reel Sound and Light Productions, hereinafter referred to as the teacher and RSL Productions, and based on terms hereinafter stated.  I hereby give the teacher and RSL Productions, her legal representatives and/or those assigned, those for whom the teacher is acting, and those acting with her permission, or her employees, hold harmless the teacher for work to learn dance performed at this address, or performance at other dance venues in the company of this teacher and RSL Productions, and in transit to and from this dance studio site.

I hereby waive any right to sue the teacher and RSL Productions and I hereby release, discharge, and agree to hold harmless the teacher, RSL Productions, her representatives and/or those assigned, employees or any person or persons, corporation or corporations, acting under her permission or authority, or any person, persons, corporation or corporations, for whom she might be acting, including any involved, in whole or in part, from and against any liability as a result of any work involved learning or in performing this dance on the premises or at other dance venues in the company of this teacher and RSL Productions.

I have read the foregoing release, authorization, and agreement, before affixing my signature below, and warrant that I fully understand the contents thereof. 

Print Name   _________________________________________________________________

 Legal Name Signature ________________________________________________Date______________

 Professional Dance Name   _____________________________________________________         

Email address: _____________________________________________________ I wish to receive dance news:   Yes _________ 

Street Address  ________________________________________________________  Apt_____________________ 

 City  ______________________________________________   State _____________ Zip code  _______________          

 Telephone:______________________________________________Mobile  phone:____________________________________

 Vehicle Color/Make/Type: ___________________________________Year______ Vehicle License ________________________

Guardian/ Emergency Contact Information

Emergency POC: ______________________________________________________________________________________________

 Print Name ___________________________________________  Relation ____________________Mobile number  _________            

 Street Address________________________________________________________ Apt_____________                 

 City ________________________________________________    State ______   Zip code____________

Initials _____________  I hereby certify that I, as the dancer engaged in dance lessons and/or performance with Ma*Shuqa and RSL Productions, carry my liability insurance and will cover any personal injury and/or illness that may result from learning dance at this studio location and/or in transit to and from dance performance events. 

 Initials _______________ I understand that dependent upon my physical condition, I may experience muscle and/or joint soreness as a result of taking dance classes and/or performing with Ma*Shuqa. 

 Initials _______________ I hereby certify that I am competent to sign a liability waiver in so far as the above information about me as a dancer is concerned.  

(Please mail or scan and attach E-mail to MaShuqaDancer@gmail.com.me