Belly Dance Class Registration Form

Belly Dance Class & Playshop Registration Form

Name:

Address:

Phone number:

Email:

Class of Choice:
(Please check one)

A Taste of Belly Dance-Level 1
in New Westminster

Method of Payment:
(Please check one)

Paying by Cheque

Paying with Cash

Please Note: Your Registration is not complete
until Payment is received.

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 and/or the Zahara Belly Dancers.

I hereby release Annyse Rayne and/or the Zahara Belly Dancers
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?