Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone *

(###)

###

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Cell Phone *

(###)

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A printed roster showing name, address and e-mail of participants will be available. May we include your information? *

Yes

No

I give FCA permission to use any picture/video of me at the 35th Anniversary Vintage Dance week in or on any form of publicity for FCA or an FCA -sponsored event. * * *

Yes

No

I understand and agree that there are risks of physical injury associated with, arising out of and inherent to the activity of dance. Possible sources of injuries include, but are not limited to, missteps, dizziness, loss of balance, slipping, falling, and colliding with other dancers or objects. In recognition of this, I agree to assume all risks and responsibility for any such injury, which I may have or which may accrue to me during the 35th Anniversary Vintage Dance Week sponsored by The Flying Cloud Academy (FCA) July 16 – 22, 2017. Furthermore, I do hereby fully exempt, release and indemnify FCA, its officers, volunteers, and/or instructors from any and all claims from injuries, damage or loss which I may have or which may accrue to me as a result of my participation in the 35th Anniversary Vintage Dance Week. *

I agree