GUTS Public ProgramParticipant Form Full Name * (as appears on ID or child's name) First Name Last Name Preferred Name Email * Phone (###) ### #### About You Please note we use this information to inform our own data around who is attending classes. The only way it is shared is in general terms (ie. 20 people between the ages of 18-25 etc.) If you do not want to provide certain pieces of this information, that is OK! I am happy to share information in a general way I do not want to share information Age of participant What is your gender identity? Female Male Non-binary Prefer not to say Do you identify with any of the following? First Nations (Australian) First Nations (Other) Person with a disability LGBTQI+ Culturally and Linguistically Diverse What is your main reason for attending dance class? Tick all that apply To learn how to be a better dancer Social health Emotional Health Other Pre-existing Medical Conditions Do you have any pre-existing medical conditions or injuries of which we should be aware? Emergency Contact Details First Name Last Name Relationship to you or the participant Emergency Contact Phone (###) ### #### Release From Liability And Negligence In exchange for authority to participate in dance classes, events and performances of Guts Dance Central Australia, I hereby grant the following release from liability and negligence. I release and hold harmless Guts Dance Central Australia and its officers, directors, employees, representatives, agents, contractors, landlords and lessees (hereafter called ‘Related Parties’) from any and all liability for injury to my person or property caused in any manner of the Related Parties by my participation in the Guts Dance Central Australia classes, events and performances. I acknowledge that the dance classes provided by Guts Dance Central Australia are physically strenuous and challenging. I understand that whilst Guts Dance Central Australia classes allow for an appropriate warm up period, participants are advised to pace themselves during the classes and take responsibility for their own health & physical safety. I acknowledge I have been advised to consult with my doctor with respect to any past or present injury, illness, cardiovascular problem or any other condition that may affect my participation in dance classes and that I knowingly execute this release from liability and negligence. I acknowledge that I may be photographed or filmed while participating in the dance classes and I hereby give permission for the use of my name and photographic likeness to be used in all forms of media for the promotion of any activity undertaken by GUTS Dance Central Australia. I agree Thank you!
