1. Healthcare

LOS ANGELES
February 14th, 2015
Mark Keppel High School
501 E. Hellman Ave
Alhambra, CA 91801
The 25th annual National Street Dance USA competition season is
open to all private dance studios, dance crews, school dance/drill
teams, and independent dance programs. The highlights of the event
consist of team performances in a variety of traditional dance styles,
as well as the extremely popular street dance divisions! If you love
hip hop, popping, locking, breaking, isolations, house, street jazz,
acro, gymnastics, tricks, and emerging contemporary dance styles...
then Street Dance USA is right where you need to be!
Please note: The Top (10) “Mr. Street Dance” soloists will qualify to
compete for the national championship solo title at MDDTUSA
Nationals & Pageant on March 25-28th, 2015.
ENTRY DEADLINE: JANUARY 23, 2015
General Information
ELIGIBILITY REQUIREMENTS
Each team Director must submit the official Street Dance USA entry
forms with team roster by mail, email or online registration.
Performers must be current students/members of the school, dance
studio, dance team, drill team or recreation program they represent.
Teams MUST enter the age division of the oldest competitor in each
routine. For example, if all team members performing in a routine
are age 13 but one of the performers in that routine is age 16, the
routine MUST compete in the Senior Division. Please take notice of
the age overlap between the Senior Division & College/Pro
Division. High school graduates are NOT ALLOWED to compete in
the Senior Division. Age divisions are organized as follows:
MINI!
!
JUNIOR ! !
SENIOR ! !
COLLEGE/PRO !
!
!
!
!
(10 yrs & under)
(11-14 yrs.)
(15-18 yrs.)
(18 yrs. & older)
MEDICAL LIABILITY/MEDIA RELEASE FORMS
On the day of the event, the team Director must turn in one signed
liability release form per competitor, or routines will be scratched!
PERFORMANCE LINE-UP SCHEDULE
Contestants compete in a randomly assigned order at a designated
time. Competition staff reserves the right to make division/size
changes. Performance line-up & final instructions will be emailed
to the team Director by February 2nd, 2015 (Note: Teams will not be
scheduled in the line-up if entry fees are not received by this
deadline). Schedule conflicts must be resolved before February 6th,
2015. On the day of the event, teams must check-in at least (1) hour
prior to their scheduled performance time.
AWARDS & SCORESHEETS
Trophies are presented to half the teams per division. Directors
receive all scoresheets when they sign-out (after awards ceremony).
ENTRY FEES
Soloists! !
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$ 70
Duet/Trio!
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$ 75
Officer! !
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$ 80
Small & Medium Team Routines! !
!
$ 90
Large Team Routines & Stand Battle!!
!
$100
Special Class Team Routines (i.e. Novelty, Pom, etc)! $ 90
Street Dance Production! !
!
$125-$150
Please make checks payable to: Miss Dance Drill Team USA.
School/Booster check or certified funds only - NO personal
checks! All fees are non-refundable.
GENERAL ADMISSION (for non-performers)
Pre-sale Price: Buy early! See entry form!
!
Door Price: Parents, Friends & Spectators!
!
Children (under 5)!
!
!
!
$7
$8
FREE
Note: All contestants and (2) directors are admitted FREE
VIDEO RECORDING & PHOTOGRAPHY
Please help protect choreographic integrity & creative rights.
Still photography is allowed, but video recording of any kind
is forbidden from the contest area (even if filming your own
team or soloist). Please advise team members, spectators &
family members of this rule... as your team may be
disqualified if caught filming (even with cell phones, ipods).
DVD recordings of performances can be purchased on-site
from our official videographer (check, cash, credit card
accepted). DVD packages are normally shipped in 2-4 weeks.
DIRECTOR/SPONSOR SUPERVISION
An adult must accompany youth teams at all times. Directors,
sponsors and chaperones are responsible for maintaining
sportsmanship & conduct/behavior of their team members.
ENTRY DEADLINE: JANUARY 23, 2015
Rules & Regulations
JUDGING CRITERIA
All routines must demonstrate formation changes & specific
technique of category entered. Performances are judged on
routine choreography, technical execution & showmanship.
Scores are averaged out of a total possible high score of 100. All
decisions of the judges are FINAL.
STREET DANCE CATEGORY GUIDELINES
Street Dance: Routine emphasis must be on any street dance style
(i.e. hip hop, popping, locking, breaking, vogue, acro, gymnastics,
street jazz, etc). Overall effect must be street dance in nature.
Step/Stomp: Emphasis on stepping or stomp dancing as a team
(Must wear rubber sole shoes... no hard soled shoes allowed!)
Street Dance Production: Emphasis is on presentation of a variety
of street dance styles, (i.e. hip hop, popping, locking, breaking,
grooves, house, etc), dynamics, artistry & cultural interpretations
that capture the look/costume, attitude, musicality, and elements
of an urban environment. Sets and props may be used, if desired.
Stand Battle: Any style of street dance/hip hop can be utilized.
Each stand must be 32-48 counts of music (4-6 eight counts). Each
team performs three times. Emphasis is on call & response, and
countering the opposing team. Winners advance to the next round
in bracket tournament style. Please see “Stand Battle Rules &
Regulations” attachment for more specific information and tips!
Duet-Trio (Street Dance): Routines are limited to 2-3 performers
of any age & in any street dance style (i.e. hip hop, street jazz, etc)
Solo (Miss & Mr. Street Dance): Routine must emphasize street
dance genres. Please Note: the Top (10) Mr. Street Dance winners in
the Senior division will qualify to compete for the Mr. Dance USA
national championship “solo title” at MDDTUSA Nationals.
DANCE/DRILL CATEGORY GUIDELINES
Jazz: Routine emphasis must be on jazz dance technique. Props
permitted but must not be the focal point of the routine.
Lyrical/Contemporary: Routine must be of a poetic style with soft,
flowing choreography & creative/dramatic movements. Much
more technical & controlled in nature than any other division. Military: Routine displays precision movements. Choreography
must demonstrate sharp angular arm sequences, a variety of
marching styles & contagion/level dynamics (kickline sequence is
allowed). Traditional military includes leading with the left foot.
Pom/Song: Routine must focus on the use of pom-pons, featuring
innovative dance and precision movements.
Novelty/Character: Routine emphasis must be on creative
characterization or be of a unique, thematic nature. Entrants must
use clever costumes and innovative moves to convey the thematic
character-driven choreography. Small sets are allowed, if desired.
Prop: Routine emphasis must be on the use and manipulation of a
prop or variety of props as the major focal point.
Open: Routine may be of any style, or combination of styles.
Duet-Trio (Jazz/Lyrical): Routine is limited to (2-3) performers &
must emphasize jazz and/or lyrical dance technique.
Solo (Jazz & Lyrical/Contemporary): Routine is limited to (1)
performer and must emphasize jazz or lyrical dance technique.
NOTE: There must be at least (3) teams in each division, otherwise
those routines will perform in the “OPEN” category. Teams
CANNOT compete against themselves in the same age division.
ROUTINE TIME LIMIT REQUIREMENTS
Teams have 30 seconds to enter/exit the floor. Timing and
judging begins with the first beat of the music and ends with the
last beat of the music. Team routines must be 2-3 minutes in
duration (Routines entered in the Street Dance Production
division must be 4-6 minutes). All solo & duet/trio routines
must be not less than 90 seconds and not more than 2 minutes.
MUSIC SUBMISSION REQUIREMENTS
All music must be recorded on a new, high quality CD with only
ONE SONG on each CD (Directors should bring a back-up CD/
ipod for emergencies). CD must be labeled & marked as follows:
School/Name
Division Category
Note: When burning music onto a CD, you MUST use blank
CD-R discs (NOT CD-RW). Please remember to “close the disc”.
COSTUMES & FOOTWEAR
Performance costumes must be in good taste, appropriate for a
family audience, and approved by the team’s Director. With
regard to footwear, our preference is performers wear soft/
rubber sole shoes; however, half-soles/bare feet are permitted.
RULES FOR USE OF PROPS AND/OR SETS
Props and sets may be used in a routine. All props/sets must be
rubber-tipped to prevent floor damage. If protective tips are not
used, the routine will be disqualified. Any damage to facilities or
performance floor caused by use of props and/or sets will result
in disqualification. Damages will be charged to the team’s school.
PENALTIES & DISQUALIFICATION
Same routine/choreo in multiple categories = Disqualification
Under/Over Time Limit = 2 point penalty (teams under/over
more than 30 seconds may be disqualified)
Entrance/Exit Music = 2 point penalty (music other than
actual routine music & not within routine timing is not allowed)
Entered in wrong category = 5 point penalty (also subject to
disqualification pending decision of the judges.
Not performing at scheduled time = 5 point penalty (not
applicable if assigned time changed by competition staff.
Performing with more/less dancers than allowed in division =
2 point penalty per person over, or under.
Crossing half-court line during stand battle = Disqualification
Non-compliance w/music submission rules = 2 point penalty
A CD must be turned in for each routine. No ipods! (backup only)
Music with bad sound quality = 2 point penalty
Bad sportsmanship by a performer, team, director or coach =
Disqualification
Inappropriate content = If dance movements, music lyrics, or
costuming are deemed to be too suggestive or inappropriate for
our family audience, the routine will be scored lower by the
judges and may result in disqualification.
Videotaping & Cell Phone Videorecording = Strictly
Prohibited. (Disqualification of your team could result if video
cameras are found in the competition arena/auditorium. Please
inform students, contestants, coaches, and families of this rule.
Coaches caught competing with students = Disqualification
ENTRY DEADLINE: JANUARY 23, 2015
New Category: Stand Battle
The Stand Battle dance competition category has exploded into mainstream culture this year after recently being featured on Lifetime’s
hit TV show “Bring It!”. The MDDTUSA organization has recognized the significance of this development, and we are very excited to
help pioneer the growth of this new division by featuring it in our national tour of Street Dance USA competitions. Additionally, this
category will also be showcased at Miss Dance Drill Team USA Nationals & World Championships. Please use the information below to
prepare your dance team, drill team, dance crew, dance company, or majorette hip hop team for this thrilling new category!
STAND BATTLE
STAND BATTLE INFORMATION, RULES & GUIDELINES
Who can enter the Stand Battle category?
This year, the stand battle category is open to teams consisting of dancers in the Senior age division (high school) and of any
composition (all female, all male, co-ed). In future years, we plan to open this division to other age divisions (junior, college-pro, etc).
Teams competing in the Stand Battle category are limited to 6-16 dancers on the floor at any given time during the performance.
What is a Stand Battle tournament?
Teams face each other from opposite ends of the gym floor and compete in a tournament bracket
format. The winning team from each grouping advances to the next round, and the process repeats.
How many teams are allowed to compete in the tournament?
The stand battle division is typically limited to 8 teams: the first 8 teams to submit their registration
entry form and fees... So turn them in early! In the event that a high number of entries are received,
we may allow up to 16 teams in the bracket. For an 8-team tournament there will be no more than 3
rounds and for a 16-team tournament there will be no more than 4 rounds (scheduled at different
times throughout the day to allow for other traditional team routine performances). For teams who
turn in their forms and fees too late and DO NOT make it into the tournament bracket, their stand
battle entry fees will be refunded to the team director only on the day of the event. Teams may not
compete against themselves (only one Stand Battle team entry allowed per age division).
What are stands & how are they used?
A “stand” is a mini-routine or choreographed series of 8-counts, in the style of hip hop or other street dance genres. Each stand must
be 32-48 counts of music (4-6 eight counts). When the stand battle begins, the captain or team leader should be positioned in the
middle of the group. When the music begins to play, the captain should quickly listen to the rhythm of the song and then signal to the
rest of their team so that the team members know which of their pre-choreographed stands to perform (the captain’s signal should be
“thrown” during the 8-count of music prior to the rest of their team joining in). One team “throws” a stand, followed by the opposing
team. This process repeats 2 more times (meaning each team performs 3 times total). The team that is scheduled to throw the first stand
will always perform first during that round (The order may change if the team advances to the next round, but this is not guaranteed).
How are teams judged?
In addition to satisfying traditional judging criteria, stand battle teams must emphasize “call & response” by outperforming the
opposing team. The team captain should throw a new stand as soon as the opposing team is finished performing their own stand
choreography (2 point penalty for any delay that exceeds 2 eight counts). Teams are NOT allowed to begin a stand when the opposing
team is still performing (disqualification). Teams are NOT allowed to cross the half-court line (disqualification).
How are winners announced?
At scheduled times throughout the day, the tournament bracket will be updated and winners from each round will be announced so
they can prepare to compete again (with the final two teams competing against each other immediately before the last high school
awards ceremony of the day). More information will be posted once the competition schedule is released.
TEAM ENTRY FORM: LOS ANGELES
Director’s Name: ____________________________________________________
Home Address: ____________________________________________________
City / State / Zip: ____________________________________________________
Phone: ______________________ Email: ________________________________
YOUTH TEAM CATEGORIES
(w/ team size limits)
Street Dance Production (25+)
Stand Battle (6-16)
Stepping/Stomp (6+)
Small Co-Ed Street Dance (6–10)
Small Female Street Dance (6–10)
Small Male Street Dance (6–10)
Small Jazz (6–10)
Small Lyrical/Contemporary (6–10)
Small Military (6–10)
Medium Co-Ed Street Dance (11–17)
Medium Female Street Dance (11–17)
Medium Male Street Dance (11–17)
Medium Jazz (11–17)
Medium Lyrical/Contemporary(11–17)
Medium Military (11-17)
Large Co-Ed Street Dance (18+)
Large Female Street Dance (18+)
Large Male Street Dance (18+)
Large Jazz (18+)
Large Lyrical/Contemporary (18+)
Large Military (18+)
Novelty/Character (6+)
Pom/Song (6+)
Prop (6+)
Short Flags - Single (3+)
Short Flags - Double (3+)
Officer (4-5)
Open (6+)
AGE DIVISION
(select box)
☐MINI ☐JUNIOR ☐SENIOR
☐SENIOR DIVISION ONLY
☐MINI ☐JUNIOR ☐SENIOR
☐MINI ☐JUNIOR ☐SENIOR
☐MINI ☐JUNIOR ☐SENIOR
☐MINI ☐JUNIOR ☐SENIOR
☐MINI ☐JUNIOR ☐SENIOR
☐MINI ☐JUNIOR ☐SENIOR
☐MINI ☐JUNIOR ☐SENIOR
☐MINI ☐JUNIOR ☐SENIOR
☐MINI ☐JUNIOR ☐SENIOR
☐MINI ☐JUNIOR ☐SENIOR
☐MINI ☐JUNIOR ☐SENIOR
☐MINI ☐JUNIOR ☐SENIOR
☐MINI ☐JUNIOR ☐SENIOR
☐MINI ☐JUNIOR ☐SENIOR
☐MINI ☐JUNIOR ☐SENIOR
☐MINI ☐JUNIOR ☐SENIOR
☐MINI ☐JUNIOR ☐SENIOR
☐MINI ☐JUNIOR ☐SENIOR
☐MINI ☐JUNIOR ☐SENIOR
☐MINI ☐JUNIOR ☐SENIOR
☐MINI ☐JUNIOR ☐SENIOR
☐MINI ☐JUNIOR ☐SENIOR
☐MINI ☐JUNIOR ☐SENIOR
☐MINI ☐JUNIOR ☐SENIOR
☐MINI ☐JUNIOR ☐SENIOR
☐MINI ☐JUNIOR ☐SENIOR
ENTRY FEE
(select box)
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School / Team: __________________________________________________________
Team Address: __________________________________________________________
City / State / Zip: __________________________________________________________
Team Type:
☐HIGH SCHOOL ☐JR. HIGH/ELEM ☐STUDIO/INDEPENDANT ☐COLLEGE/PRO
DUET-TRIO: STREET DANCE
(please list FIRST names only)
AGE DIVISION
(select box)
☐JUNIOR
☐JUNIOR
☐JUNIOR
☐JUNIOR
$125
$100
$ 90
$ 90
☐SENIOR
☐SENIOR
☐SENIOR
☐SENIOR
ENTRY FEE
(select box)
☐COLLEGE/PRO
☐COLLEGE/PRO
☐COLLEGE/PRO
☐COLLEGE/PRO
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$ 75
$ 75
$ 75
$ 75
$ 90
$ 90
$ 90
DUET-TRIO: JAZZ/LYRICAL
(please list FIRST names only)
AGE DIVISION
(select box)
☐JUNIOR
☐JUNIOR
☐JUNIOR
☐JUNIOR
$ 90
$ 90
$ 90
$ 90
☐SENIOR
☐SENIOR
☐SENIOR
☐SENIOR
ENTRY FEE
(select box)
☐COLLEGE/PRO
☐COLLEGE/PRO
☐COLLEGE/PRO
☐COLLEGE/PRO
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$ 75
$ 75
$ 75
$ 75
$ 90
$ 90
$ 90
ADULT TEAM CATEGORIES
(w/ team size limits)
$ 90
Street Dance Production (25+)
$100
Mens Street Dance (6+)
$100
Ladies Street Dance (6+)
$100
Co-Ed Street Dance (6+)
$100
Open (6+)
AGE DIVISION
(select box)
☐COLLEGE/PRO
☐COLLEGE/PRO
☐COLLEGE/PRO
☐COLLEGE/PRO
☐COLLEGE/PRO
ENTRY FEE
(select box)
DIVISION ONLY
DIVISION ONLY
DIVISION ONLY
DIVISION ONLY
DIVISION ONLY
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$150
$100
$100
$100
$100
$100
$100
$ 90
$ 90
$ 90
$ 90
$ 90
$ 80
$ 90
DIRECTORS! PLEASE CAREFULLY COMPLETE THE SUBTOTAL WORKSHEET BELOW:
= _________
SUBTOTAL ‘SOLO’ FEES (ATTACH CONTESTANT FORM FOR EACH SOLOIST)
= _________
LATE REGISTRATION FEE: $25 (INCLUDE IF SUBMITTED AFTER DEADLINE)
= _________
GENERAL ADMISSION TICKETS: __________ x $7/each (PRE-SALE PRICE) = _________
GRAND TOTAL COMPETITION FEES = _________________
SUBTOTAL ‘TEAM’ FEES (REQUIRED: ALL ROUTINES FROM THIS PAGE ONLY)
PLEASE MAKE CHECK OR MONEY ORDER PAYABLE TO “MISS DANCE DRILL TEAM USA”
(SCHOOL/BOOSTER CHECK OR CERTIFIED FUNDS ONLY - NO PERSONAL CHECKS ACCEPTED)
MAIL COMPLETED ENTRY FORM(S) & FEES TO:
ENTRY DEADLINE: JANUARY 23, 2015
PLEASE CAREFULLY READ ALL OFFICIAL STREET DANCE USA RULES & REGULATIONS.
COPYRIGHT NATIONAL STREET DANCE USA, aka MISS DANCE DRILL TEAM USA 501(c)(3) 1968-2015
COPYRIGHT ALL FORMS, SCORESHEETS & PROCEDURES (1968-2015)
MISS DANCE DRILL TEAM USA
32565 B GOLDEN LANTERN #357
DANA POINT, CA 92629
PHONE: (562) 628-9181
FAX: (949) 487-7769
EMAIL: [email protected]
WEB: www.MDDTUSA.com
SOLOIST ENTRY FORM: LOS ANGELES
CONTESTANT INFO
TEAM/DIRECTOR INFO
AGE DIVISION (choose one)
Full Name:
______________________________________
Team Name:
____________________________________
Address:
______________________________________
Director’s Name:
____________________________________
City/State/Zip: ______________________________________
Director’s Phone:
____________________________________
Home Phone:
______________________________________
Director’s Email:
____________________________________
☐ MINI
☐ JUNIOR
☐ SENIOR
☐ COLLEGE/PRO
Email:
______________________________________
Birthdate:
______________________________________
PARENT/GUARDIAN INFO (youth solos only)
SOLOIST CATEGORY (choose one)
Age:
______________________________________
Parent Name:
____________________________________
Parent Phone:
____________________________________
Parent Email:
____________________________________
☐ MR. STREET DANCE
☐ MISS STREET DANCE
☐ LYRICAL/CONTEMPORARY
☐ JAZZ
(AGE 10 & UNDER)
(AGE 11-14)
(AGE 15-18)
(AGE 18 & OLDER)
$70
$70
$70
$70
EXTRA FEES (if applicable)
☐ LATE ENTRY (AFTER DEADLINE)
TOTAL FEES:
$25
_______________________
PARTICIPATION AGREEMENT:
Contestant agrees that the time, manner & method of judging the contest shall be solely within the discretion of the MDDTUSA committee, and that the decision of the judges will be final. Contestant
agrees that the committee reserves the rights to upon request conduct preliminary judging if necessary (Time to be announced at a later date). Contestant agrees that if he/she is selected as the
winner of this contest, he/she will not sign management contracts with any individual or corporation, and that he/she will not give any written or verbal endorsement of any mercantile commodity or
commercial organization, nor will he/she permit any photographs to be used in connection with any advertised commodity or MDDTUSA services not associated with this contest, without the
permission of the Producer of National Street Dance USA, and that he/she will seek and make public appearances to promote the pageant. As a contestant in the National Street Dance USA solo
competition, I hereby acknowledge that I have read the official competition rules and regulations, that I am complying with them in every way, and that the personal data herein set forth is correct. I
hereby agree that I shall make no claim upon any person or persons connected with the event for use of photographs, for injuries or damages suffered by me, if any, for invasion of rights of privacy
or property or personal interest by reasons of the conduct of this contest or by reason of publicity or any public display thereof including radio, picture, television presentation, and commercial rights
where Contestant appears. National Street Dance USA may use all photographs of my image and likeness at its discretion. In the event any Street Dance USA competition is televised, my
participation in this contest is an agreement to be televised, and I understand the format of the competition may be changed to accommodate television production and broadcasting.
_____________________________________________________________
______________________________________________
Contestant’s Signature
Date
_____________________________________________________________
______________________________________________
Parent/Guardian Signature (required if contestant is a minor under age 18)
Date
ENTRY DEADLINE: JANUARY 23, 2015
NOTE: DIRECTORS MUST USE A SEPARATE FORM FOR EACH SOLO TITLE CONTESTANT. IF ALSO ENTERING
TEAM CATEGORIES, SEND SOLOIST PAYMENT WITH TEAM ENTRY FORM (IF POSSIBLE). FINAL
INSTRUCTIONS FOR SOLOIST CONTESTANTS WILL BE EMAILED TO CONTESTANT’S DIRECTOR. PLEASE
READ ALL STREET DANCE USA SOLOIST RULES, REGULATIONS & JUDGING REQUIREMENTS CAREFULLY.
MAIL OR EMAIL COMPLETED ENTRY FORM(S) & FEES TO:
MISS DANCE DRILL TEAM USA
32565 B GOLDEN LANTERN #357
DANA POINT, CA 92629
_____________________________________________________________
______________________________________________
Team Director Signature
Date
COPYRIGHT NATIONAL STREET DANCE USA, aka MISS DANCE DRILL TEAM USA 501(c)(3) 1968-2015
PHONE: (562) 628-9181
FAX: (949) 487-7769
EMAIL: [email protected]
WEB: www.MDDTUSA.com
TEAM ROSTER (write/type team name): ___________________________________
In an effort to avoid as many “quick changes” as possible, please use the following team roster form to list ALL your team participants. Please remember to list
ALL routines that each participant will be performing in so that we can plan our competition performance line-up order. We want to ensure that all participants
have a fair amount of time to change costumes and prepare for their next performance. (copy this form & attach additional pages, if needed).
Name of Dancer
Routines Entered (for each dancer)
Name of Dancer
1)
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Routines Entered (for each dancer)
MEDICAL RELEASE, LIABILITY RELEASE & MEDIA RELEASE FORM
Performer’s Name: __________________________________________
Team Name: _______________________________
Date of Birth: ______________________________________________
Age: ______________________________________
1.
I understand that by taking part in this or any contest, there is a possibility of injury or sickness to participant(s); therefore, with this knowledge
I give permission for the above named performer to participate in the National Street Dance USA Competition, and do hereby grant permission
to hospital staff members to administer immediate treatment to the above named participant should he/she become injured or ill.
2.
I agree to hold harmless Miss Dance Drill Team USA and their respective officers, directors, employees, agents, contractors, charters,
subsidiaries, affiliates, sponsors, and parent companies for any injury incurred as a result of the above-named performer’s participation in the
contest even if shown that they are negligent.
3.
I also grant permission for Miss Dance Drill Team USA to use the above-named participant’s image or likeness in any and all promotional
materials for event marketing purposes (such as brochures, website media, social media, video publication services, etc), and do so with no right
to monetary compensation for the above stated usage terms. I understand the above-named participant may be photographed for such
purposes, and release all rights to media acquired for MDDTUSA-affiliated promotional purposes.
Signature: ___________________________________________
Parent’s Name: ___________________________________
(must be parent’s signature if participant is under 18)
(leave blank if participant is over 18)
Address: _______________________________________________________
State: __________
Home Phone: _______________________ Work Phone: ________________________
Zip: ________________
Cell: ________________________
Insurance Company: _______________________________________ Policy Number: ______________________________
Medication Allergies: _____________________________________________________________________________________
Family Physician: __________________________________________ Phone: ______________________________________
MEDICAL RELEASE, LIABILITY RELEASE & MEDIA RELEASE FORM
Performer’s Name: __________________________________________
Team Name: _______________________________
Date of Birth: ______________________________________________
Age: ______________________________________
1.
I understand that by taking part in this or any contest, there is a possibility of injury or sickness to participant(s); therefore, with this knowledge
I give permission for the above named performer to participate in the National Street Dance USA Competition, and do hereby grant permission
to hospital staff members to administer immediate treatment to the above named participant should he/she become injured or ill.
2.
I agree to hold harmless Miss Dance Drill Team USA and their respective officers, directors, employees, agents, contractors, charters,
subsidiaries, affiliates, sponsors, and parent companies for any injury incurred as a result of the above-named performer’s participation in the
contest even if shown that they are negligent.
3.
I also grant permission for Miss Dance Drill Team USA to use the above-named participant’s image or likeness in any and all promotional
materials for unlimited event marketing purposes (such as brochures, website media, social media, video publication services, etc), and do so
with no demands or rights to monetary compensation for the above stated usage terms. I understand the above-named participant may be
photographed during the event for such purposes, and release all rights to media acquired for MDDTUSA-affiliated promotional purposes.
Signature: ___________________________________________
Parent’s Name: ___________________________________
(must be parent’s signature if participant is under 18)
Address: _______________________________________________________
(leave blank if participant is over 18)
State: __________
Home Phone: _______________________ Work Phone: ________________________
Zip: ________________
Cell: ________________________
Insurance Company: _______________________________________ Policy Number: ______________________________
Medication Allergies: _____________________________________________________________________________________
Family Physician: __________________________________________ Phone: ______________________________________