EVENTS IN MOTION "PERFORMER" WAIVER
Name_______________________________________
Age ______________
Street
Address__________________________________________________
City
__________________________ State___________ Zip _____________
Home
Phone _______________________ Cell Phone __________________
Email
_________________________________________________________
Release
I,
_________________________ do hereby release Events in Motion, Ellen
Menking Hess, staff and agents from any and all liability for injury to myself
incurred by reason of participation in functions, at rehearsals, shows, events,
classes, during transportation to and from any event or activity. I acknowledge
that I am physically and emotionally able to participate. I, the undersigned,
acknowledge that I have read and understand the above and that I knowingly
execute this release from liability and negligence.
Signed___________________________________
Date____________________
Health
Insurance Company_________________ Policy Number_____________
Emergency
contact name and phone number ___________________________
Please
supply any pertinent medical information
_______________________________________________________________
EVENTS IN MOTION