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Student's First Name:
Student's Last Name:
How did you find out about The Dust Palace?
If you were referred by a friend, tell us their name!
Is there anything else we should know about you?
Past experience, fitness level, injuries, special needs, etc?
1. The Dust Palace endeavors to create as safe an environment as is possible when training aerial circus skills; with a fully comprehensive risk management system, first aid training for staff, first aid onsite at all times and regularly checked equipment. 2.RULES AND REGULATIONS I understand that the rules and regulations given by The Dust Palace staff are important to ensure the safety of all participants, and must be respected at all times. NOTE: (Should you at any time feel unsafe or compromised by the environment or actions of staff please speak with Eve Gordon 021822236) 3. Waiver of liability, release of all claims, risk assumptions and indemnification agreement. By signing this, you agree not to enter into legal proceedings and lawsuits with The Dust Palace Productions Ltd or any sub-contractor working for them. Description of Risks: THE FOLLOWING DESCRIBES SOME OF THE RISKS OF AERIAL AND ACROBATIC WORK AND THE USE OF ITS INFRASTRUCTURES. - Slips, trips, falls or painful crashes while using the facilities or aerial equipment, landing mats, floors below aerial equipment, bathroom facilities, and/or stairs; - Injuries resulting from falling, including but not limited to, falling onto persons, falling and coming into contact with any walls, structures or ropes, or falling to the floor. I understand that the description of these risks are not complete and that other unknown or unanticipated risks may result in injury, or death. 4. ACKNOWLEDGEMENT of RISK I acknowledge that: - The activities that form part of The Dust Palace classes and training involve the risk of physical harm. - I may be injured while performing the activities. - I may cause injury to other people while performing these activities. - I have disclosed any pre-existing medical or other conditions that may affect my ability to engage in the activities. - The Dust Palace relies on the information provided by the participant. I state that the information I have provided is, to the best of my knowledge, accurate & complete. - I have not relied upon any advice provided by The Dust Palace in deciding to (a) take part in the activities; and (b) sign this document. I acknowledge, agree to and voluntarily assume all risks involved, of harm, injury or damage in participating in the activity. I agree to wholly indemnify The Dust Palace, its employees and contractors from any liability arising out of injury, loss or damage caused by me (the participant) as a result of participation in the activity. I agree to comply with all rules & directions made or given by The Dust Palace & its employees & contractors in connection with the activities. I give permission for The Dust Palace to seek medical attention, including an Ambulance, at my expense, in the event that I (the participant) am injured. Occasionally during classes & other activities run by The Dust Palace some promotional images are taken. I give The Dust Palace permission to use these images.
I have read and agreed to the waiver of liability written above.
Please have the student type their
full name below as a digital signature:
If the student is a minor, please type
full name as their parent or legal guardian:
Signed Wed, Oct 16th 2019 at 3:05 AM
Are you a human?
(Sorry, robots don't make very good aerialists.)