Secure On-line Registration Form

Dear Parent/Guardian of Future Circus Star:

Step right up to the wonderful world of the circus! We are thrilled to have your child joining us for this once-in-a-lifetime experience. Please read, fill-out and return the registration and release forms. We must have these forms signed by you and on file for your child to participate in the class.

Children should wear workout clothes such as leotards, leggings or shorts (nothing too baggy or made of slick nylon). Your child will need to be barefoot for some activities. If they have rubber-soled acrobatic shoes or water shoes you may bring them but they are not absolutely necessary. A regular shoe would be helpful for stiltwalking. Shirts need to be tucked in and long hair tied back. We suggest a glasses strap if your child wears glasses. Jewelry of all kinds should not be worn in the class.

At Circus Harmony, safety is taken very seriously. Every reasonable precaution (and then some) will be taken to keep any and all students from injury or harm. However, the very nature of circus skills requires the participants to often be off the ground and/or upside down.

Our insurance company has asked that everyone involved in any of our programs read and sign the Participant Agreement, Release And Assumption of Risk. (Even if you register and pay on-line, you will need to sign a paper copy of these forms.) If the participant is a minor, their respective parent/guardian must sign. Please note: we did not write the form. This is the wording and form that our insurance company has asked us to use.

If you have any questions, please do not hesitate to contact Jessica Hentoff at Circus Harmony at 314-436-7676. We look forward to working with your child and sharing with them the joy and excitement of the circus.

Circusfully,

Jessica Hentoff
and the Staff of Circus Harmony

Select Summer Camp:

Are you eligible for a discount?	Yes No
If so, which one do you want:	Sibling Discount Multiple Session Discount None
Total Fee:

In the event that emergency medical attention is needed for my son/daughter, I understand that the Circus Harmony and its employees will make every effort to contact me immediately. In the event that I cannot be reached, I release medical authorization to Circus Harmony and its employees to obtain the necessary emergency medical attention for my son/daughter until I am reached.

By signing this form, you are granting the Circus Harmony the right to photograph and otherwise record and use my child’s picture, silhouette and other reproductions of their physical likeness, and voice recording (as the same may appear in any still camera photograph and/or video, motion picture film, or television program), in and with the exhibition, theatrically, on television or otherwise in any other medium, of any video, motion picture or television program in which they may be used or incorporated, and also in advertising or publicizing of the same.

Student’s Name:
Student’s Gender:	MaleFemale
Student’s Age:
Student’s birth date: (mm/dd/yyyy)
Parent/Guardian’s Name:
Home Phone Number:
Work Phone Number:
Cell Phone Number:
Address:
City:
State:
Zip:
E-mail:
Re-type E-mail:
How did you hear about Circus Harmony?

I have read this Consent and Release and fully understand and consent to the above.

Payment Method

3. PARTICIPANT AGREEMENT, RELEASE AND ASSUMPTION OF RISK

In consideration of the services of Circus Harmony, their agents, owners, officers, volunteers, participants, employees, and all other persons or entities acting in any capacity on their behalf (hereinafter collectively referred to as “CDF”), I hereby agree to release, indemnify, and discharge CDF, on behalf of myself, my spouse, my children, my parents, my heirs, assigns, personal representative and estate as follows:

1. I acknowledge that taking a clinic in circus skills entails known and unanticipated risks that could result in physical or emotional injury, paralysis, death, or damage to myself, to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity.

   The risks include, among other things: Circus activities entails certain risks that simply cannot be eliminated without jeopardizing the essential qualities of the activity. Without a certain degree of risk, circus students would not improve their skills, and the enjoyment of the activities would be diminished. Circus activities expose its participants to the usual risk of cuts and bruises. Other more serious risks exist as well. Participants can fall off equipment, sprain or break wrists and ankles, and can suffer more serious injuries as well. Traveling to and from shows, meets or exhibitions raises the possibility of any manner of transportation accidents. In any event, if you or your child is injured, your or your child may require medical assistance, at your own expense.

   Furthermore, CDF employees have difficult jobs to perform. They seek safety, but they are not infallible. They might be unaware of a participant‘s fitness or abilities. They may give incomplete warnings or instructions, and the equipment being used might malfunction.

2. I expressly agree and promise to accept and assume all of the risks existing in this activity. My participation in this activity is purely voluntary, and I elect to participate in spite of the risks.

3. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless CDF from any and all claims, demands, or causes of action, which are in any way connected with my participation in this activity or my use of CDF’s equipment or facilities.

4. Should CDF or anyone acting on their behalf, be required to incur attorney’s fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.

5. I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or else I agree to bear the costs of such injury or damage myself. I further certify that I am willing to assume the risk of any medical or physical condition I may have.

6. In the event that I file a lawsuit against CDF, I agree to do so solely in the state of Missouri, and I further agree that the substantive law of Missouri shall apply in that action without regard to the conflict of law rules of that state. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining document shall remain in full force and effect.

   By signing this document, I acknowledge that if anyone is hurt or property is damaged during my participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against CDF on the basis of any claim from which I have released them herein.

I have had sufficient opportunity to read this entire document. I have read and understood it, and I agree to be bound by its terms.

Date:

Student’s Name:
Address:
City: State: Zip:

PARENT’S OR GUARDIAN’S ADDITIONAL INDEMNIFICATION

I AgreeI disagree (or doesn't apply)
In consideration of (“Minor”) being permitted by CDF to participate in its activities and to use its equipment and facilities, I further agree to indemnify and hold harmless CDF from any and all claims which are brought by, or on behalf of Minor, and which are in any way connected with such use or participation by Minor.

Parent or Guardian’s Name: Date: