Workshops in Open Fields Registration Form

The Brainerd Heritage Project

Registration: Saturday May 22, 2010
9:30 am – 10:30 am
Saturday, May 22, 2010 10:30 am – 4:00 pm
Sunday, May 23, 2010 2:00pm -4:00 pm
Name: _______________________________________________________________________
Last First M.I.

Age:___________

Address: _______________________________________________________________

City/State/Zip: __________________________________________________________

Home Phone/Cell Phone: __________________________________________________

Email Address: __________________________________________________________

Current Dance Studio: ________________________________________________________________

Dance Studio Address:
___________________________________________________________________________________

__ Check here if you are participating both days

__ Check here if you are participating only May 22, 2010
__ Check here if you are participating only May 23, 2010

HOLD HARMLESS AGREEMENT

As a participant of the Debbie Allen Dance Academy “Open Fields Workshops”, I __________________________ do hereby
assume all risk associated with participation in the “Open Fields Workshops”. I agree to indemnify, defend and hold harmless The
Brainerd Institute, ADEPT, and the Debbie Allen Dance Academy, their agents, employees, officers, directors, successors and
assigns. I fully and forever release and discharge such parties from any and all claims, demands, actions, causes of actions, suits,
controversies, obligations and liabilities of any kind and nature whatsoever (collectively referred to as Claims) relating to personal
injury or property damage sustained, incurred, or caused by aforedescribed program or any other events and occurrences while said
person is engaged in the Program or any other activity related thereto.

The foregoing assumption of risk, aforement to indemnify and release shall further be inapplicable to and of no force and effect for
any and all Claims asserted against any third party independent contractor performing services for compensation in connection
with the Activities, except to the extent and amount that such third party independent contractor has a valid right, and claim for
contribution, reimbursement or indemnify which is not covered by the above described insurance and is asserted against the The
Brainerd Institute, ADEPT, and the Debbie Allen Dance Academy, their agents, employees, officers, directors, successors and
assigns.

Signature: ____________________________________________________________ Date: __________________

The Debbie Allen Dance Academy, ADEPT., and The Brainerd Institute Memorial Project does not discriminate with respect to race,
ethnicity, culture, gender, age, and physical disabilities. For more information, please visit our website at debbieallendanceacademy.com.

Please complete and fax registration form to (310) 280‐0227 before May20th. 
If you miss the May 20th deadline you may bring a completed registration form 
with you on May 22nd at 9:30am.