**2025 Summer Street Dance Intensive**

**Student Registration**

Please fill out the form below to register. After submitting, you’ll be redirected to the payment portal to complete your registration.

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

T-shirt Size

Birthday

YYYY

Tell us about your dance experience:

Parent/Guardian Name:

(If under 18)

First Name

Last Name

Parent/Guardian Email

(If under 18)

Parent/Guardian Phone

(If under 18)

(###)

###

####

Student Emergency Contact Name

First Name

Last Name

Emergency contact relationship to student:

Emergency Contact Phone

(###)

###

####

Emergency Contact Email

STUDENT AGREEMENT: Waiver of Liability, Assumption of Risk & Likeness Release

I agree and consent to the following: I am voluntarily participating in a 5-week dance intensive conducted by 10K Movement, LLC. I recognize the program requires physical exertion that may be strenuous at times and may cause physical injury. I am fully aware of the risks and hazards involved, and assume any responsibility to consult with a physician prior to and regarding my participation in the above-mentioned program. I verify and affirm that I have no medical condition that would prevent my participation in this program. I agree to assume full responsibility for any risks, injuries, or damage known or unknown that I might incur as a result of participating in this program. Such injuries may include but are not limited to, heart attacks, muscle strain-pulls-tears, broken bones, shin splints, heat prostration, knee-back-foot injuries, soreness, illness or other injuries including death. I likewise assume all responsibility of risk, including of property damage. I knowingly, voluntarily, and expressly waive any claims against 10K Movement, LLC, for any injury or damages that I may sustain as a result of participating in this community program. My signature below also acknowledges that I agree to being videotaped, audio recorded, and photographed during the SSDI program and associated 10K Movement events. 10K staff may modify the images and/or recordings for any and all uses, including but not limited to advertisements and marketing. I permit the use of my name, voice and likeness to 10K Movement for their purposes, in perpetuity without any payable royalties or compensation. If the participant is not 18 years of age or older, he/she must have the consent of a parent or guardian who will also read, understand, and agree to the aforementioned terms. If applicable, the Parent or Guardian must sign below and assume responsibility. I have read the above waiver and release of liability and fully understand its content. My name below represents my written signature, and as confirmed voluntarily agreement to the above terms and conditions:

Name

First Name

Last Name

Date

YYYY

Thank you for your interest & commitment to the 2024 Summer Street Dance Intensive! The 10K Staff Member will be in touch with you soon.

Click to Pay TUITION now!