STUDENT BELLY DANCE REGISTRATION FORM
STUDENT NAME___________________________________________________________
ADDRESS________________________________________________________________
PHONE__________________________________________________________________
EMAIL___________________________________________________________________
SPECIAL MEDICAL CONDITIONS_____________________________________________
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CLASS NAME (Please choose from the following):
*LEVEL 1 ABSOLUTE BEGINNER - *LEVEL 2 INTERMEDIATE - *LEVEL 3 INTERMEDIATE / ADVANCED – *MIXED LEVEL EGYPTIAN
CLASS NAME______________DAY_______________LOCATION___________________
CLASS NAME______________DAY_______________LOCATION___________________
TOTAL ENCLOSED_________________ (Cash or check only)
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CANCELATION POLICY: Your tuition will be fully refunded only if the instructor cancels a class session.
In the event of a postponed class or Holiday, the session will be extended and the students will not be shorted a class.
WAIVER (please print): I______________________________ am aware that I am engaging in a physical activity and take full responsibility of my health and welfare as a participant in this class or classes. I waive and release any claim or right to sue Madrin'ha(Hollie Wolf) and class facility for any claim, injury or personal loss or damages.
SIGNATURE_____________________________________________________
DATE__________________________________________________
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6 WEEK SESSION: $83.00 (EXCEPT LEVEL 3 CLASSES)
MIXED LEVEL EGYPTIAN: $10/SINGLE CLASS OR $8.00 WITH CLASS CARD. (Simone Studio Brandon location & Jackies Dance Studio only.)
WWW.MADRINASMID-EASTDANCE.COM HJWOLF13@AOL.COM #(813)340-5101
