Back to School Jam 2022

Culture Shock Las Vegas invites school ages to college students  to come to enjoy the dynamic new workout trend that is revitalizing the dance industry.  The Back to School Jam is music, culture, attitude, and the dance extravaganza to ever burst in Southern Nevada.  The Back to School Jam participants will relax into the fun of dancing as the world’s most innovative and elite choreographers/ instructors lead you to a world of expression.
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Back to School Jam sponsored by DEAEFYP, CSLV, Give Tribe, Vegas Cares
Participants Full Name ( First & Last Name) *
Please fill 1 per participant.  
Reserve your spot(s)
Age of Participant *
Level of Participant *
Gender
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Parent/ Legal Guardian Name (First Last Name) under 18
Contact Information phone number *
Email Address *
Comments:  list allergies
School Attended *
MEDICAL RELEASE In the event you are unable to reach me, in the case of accident or injury, I give my permission for treatment as deemed necessary by staff or emergency personnel.  I also release Culture Shock Las Vegas and its staff of liability in case of injury or accident incurred. *
The undersigned recognized that being a part of the Studio class/Pre-audition class/Training Class/ Workshops, member/instructor involves a risk of physical injury or death and hereby expressly agrees to assume all risk of injury in its entirely, from participating in Culture Shock’s function, regardless of the cause, in consideration for the opportunity to participate in Culture Shock program.  This release shall be governed by the laws of Nevada.  The undersigned hereby voluntarily and forever releases, discharges, waives and relinquishes any and all actions, causes of action or claims for negligence, personal injury, property damage or wrongful death, against, Culture Shock, its landlord, agents, and agrees that under no circumstances will be undersigned present any claim for negligence, personal injury, property damage or wrongful death against, Culture Shock, its landlord, or against from any and all such claims and causes of action.    IT IS THE INTENTION OF THE UNDERSIGNED, BY SIGNING THIS RELEASE, TO EXEMPT AND RELIEVE Culture Shock’s Program, CULTURE SHOCK, ITS LANDLORD, AGENTS, BOARD MEMBERS, VOLUNTEERS AND EMPLOYEES FROM ALL LIABILITY FOR INJURY CAUSED BY THEIR NEGLIGENCE, PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH INFLICTED UPON THE UNDERSIGNED ARISING OUT OF THE UNDERSIGNED’S INVOLVEMENT IN A CULTURE SHOCK FUNCTION AND THE UNDERSIGNED HEREBY EXPRESSLY ASSUMES ALL RISK OF PARTICIPATING IN A CULTURE SHOCK FUNCTION.  I attest and verify that I have full knowledge of the risks involved, and I am in good health physically able to participate.  If for some reason there is doubt, I have the approval of any doctor to participate.  I acknowledge the contagious nature of Covid19 and other contagious diseases and viruses and voluntarily assume the risk that I/or my children may be exposed or infected by Covid 19 by attending and participating and that such exposure or infection may result in personal injury, illness, permanent disability, and/or death.  I understand the risk of becoming exposed or infected by Covid 19 and other contagious diseases and viruses may result from the actions, omissions or negligence of myself and others, including but not limited to, employees, volunteers, and program participant and their families.  I have read and understood all studio policy information.   *
Media Release Form At times during the year, news media may ask to interview, photograph, audiotape, and film and / or videotape participants. This material may be utilized in media that includes, but is not limited to, the following: newspaper articles, television coverage,websites, Facebook, social media, internal or external publications, newsletters, video presentations, and Culture Shock® presentations. Your signature on the form below authorizes Culture Shock to release your name, photograph, and/or audio/video/filmproduction for publication related to the Culture Shock’s functions and activities. Examples may include, but are not limited to, participant activities, individual or group achievements, sporting events, performances, and/ or discussion forums.Once signed and dated, this form shall remain in effect until the end of the current performance year. At any time during the year, however, you may revoke this permission for future use by notifying in writing, the director of Culture Shock. *
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