Belly Dance Class Registration Form

Belly Dance Class & Playshop Registration Form

Name:

Address:

Phone number:

Email:

Name of Class(es) or
Playshop, Day & Time:

Method of Payment:
(Please check one)

Paying by Cheque

Paying with PayPal

Paying with Cash

I accept full responsibility for any personal injuries incurred
as a result of my participation in the Belly Dance classes or
playshops with Annyse Rayne.

I hereby release Annyse Rayne from any liability now or in the
future for any health conditions that I may obtain in class.

I hereby affirm that I have read and fully understand
the above statements.

I affirm (check box to the right)

Do you experience any medical issues ? Please explain.

How did you hear about us?