April 15th , 2017 Orange Blossom Ball Team Events
*Formation Team Members not competing in the regular competition are required to BUY A
$10 ADMISSION TICKET PER PERSON. ($15 AFTER DEADLINE) DEADLINE FOR PAYMENT: MARCH 27TH
Must Provide Full List of Names of Formation Team Members with Entry
ALL FORMATION AND EXHIBITION PARTICIPANTS NEED TO BE PRESENT IN
BALLROOM ONE HOUR PRIOR TO THEIR PERFORMANCE TIME
Formation Team Entry
College/Studio
Dance being performed
Entry Fee $45
($55 after March 27, 2017 Deadline)
Exhibition
Exhibition Performance
Performance Entry
Entry
College/Studio
Dance being performed
Entry Fee Per Performance $35
($45 after March 27, 2017 Deadline)
Team Match
College/School to Participate
Team Match: Dances to be performed:
American Bolero
Int. Foxtrot
Rhythm or Latin TBA
FREE Entry for Team Match
Smooth or Standard TBA
Nat Biedak Memorial Award
A Scholarship Award In Memory of Mr. Nathan Biedak will be given to the
Couple obtaining the highest Score in one of the Team Match Events
FREE Entry
for Team
DEADLINE
FORMatch
ENTRIES
MARCH 27th, 2017
Total Fees for Formation/Performance Entries from Above: $ ...........................
Total for all $10 Admission Tickets for Formation-Only Competitors: $ ...........................
TOTAL ________________
No Credit Cards - Make Check or Money Order Payable to Dancesport at UCR
Mail to: Fook Tham, University of California Riverside
Chemistry Department, 501 Big Springs Rd., Riverside, CA 92521-0403
Ph. 951.827.4645
e-mail: [email protected]
Participant's name: ___________________________________________
Please Print
UNIVERSITY OF CALIFORNIA, RIVERSIDE
Orange Blossom Ball: Ballroom & Latin Dance Competition
Waiver of Liability, Assumption of Risk, and Indemnity Agreement
Waiver: In consideration of being permitted to participate in any way in
DanceSport at UCR Ballroom & Latin Dance Competition April 15, 2017 at UCR SRC
hereinafter called "The Activity", I, for myself, my heirs, personal representatives or assigns, do hereby
release, waive, discharge, and covenant not to sue The Regents of the University of California, its
officers, employees, and agents from liability from any and all claims including the negligence of
The Regents of the University of California, its officers, employees and agents, resulting in
personal injury, accidents or illnesses (including death), and property loss arising from, but not limited
to, participation in The Activity.
________________________________________
Signature of Parent/Guardian of Minor
Date
________________________________
Signature of Participant
Date
Assumption of Risks: Participation in The Activity carries with it certain inherent risks that cannot be
eliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity to
another, but the risks range from 1) minor injuries such as scratches, bruises, and sprains 2) major
injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions to 3)
catastrophic injuries including paralysis and death.
I have read the previous paragraphs and I know, understand, and appreciate these and
other risks that are inherent in The Activity. I hereby assert that my participation is voluntary and
that I knowingly assume all such risks.
Indemnification and Hold Harmless:
I also agree to INDEMNIFY AND HOLD The Regents of
the University of California HARMLESS from any and all claims, actions, suits, procedures, costs,
expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement in
The Activity and to reimburse them for any such expenses incurred.
Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of
risks agreement is intended to be as broad and inclusive as is permitted by the law of the State of
California and that if any portion thereof is held invalid, it is agreed that the balance shall,
notwithstanding, continue in full legal force and effect.
Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, and
indemnity agreement, fully understand its terms, and understand that I am giving up substantial
rights, including my right to sue. I acknowledge that I am signing the agreement freely and
voluntarily, and intend by my signature to be a complete and unconditional release of all liability
to the greatest extent allowed by law.
_______________________________________
Signature of Parent/Guardian of Minor
Date
Participant's Age (if minor) _____
____________________________________
Signature of Participant
Date
Vol Waiver 7/01
2017 Orange Blossom Ball Formation Group Waiver Form
*Formation Team Members not competing in the regular competition are required to BUY A
$10 ADMISSION TICKET PER PERSON. ($15 AFTER DEADLINE) DEADLINE FOR PAYMENT: MARCH 27TH
Must Provide Full List of Names of Formation Team Members with Entry
Group Name:___________________________
Please Print
GROUP WAIVER
Acknowledgement of Understanding: I acknowledge that I have read the attached
Waiver of Liability, Assumption of Risk, and Indemnity Agreement and fully
understand its terms. I affirm that I am voluntarily participating in the
Orange Blossom Ball Dance Competition and further acknowledge that I know, understand,
and appreciate the inherent risks of the Orange Blossom Ball Dance Competition . I assume full
responsibility for any and all injuries or damages which may occur to me as a result of
the inherent risks associated with Orange Blossom Ball Dance Competition .
Print
Sign
Date
Print
Sign
Date
Print
Sign
Date
Print
Sign
Date
Print
Sign
Date
Print
Sign
Date
Print
Sign
Date
Print
Sign
Date
Print
Sign
Date
Print
Sign
Date
Print
Sign
Date
Print
Sign
Date
Group Waiver 7/01
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Total
Amount Paid
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Name of Follower
Total
Amount Paid
Must provide
of Names
of Formation
Members
Entry
Must
Providefull
Fulllist
List
of Formation
Team Team
Members
with with
Entry,
Signed Waiver & Payment
Combined Total of All Formation Team Entries
Name of Leader
$10 if not competingOrange
in Regular Blossom
Competition ($15
27th): Zero
$ if competing
in other Events
Ballafter: March
Formation
Team
Roster
Orange Blossom Ball : Formation Team Roster