Cassiopeia's Bellydance Registration Page

CASSIOPEIA’S BELLYDANCE

REGISTRATION FORM
Fit Sisters, 1715 Broadway, Vancouver WA  

Student's name___________________________________________________________________

Street__________________________________________________________________________ 

City___________________________________ State____________________ Zip ____________ 

Phone [____]_________________________  Email______________________________________ 

Emergency Contact _____________________________________ Phone ____________________ 

Do you have any ailments or restrictions?   Yes  / No   If yes, please explain ________________________________________________________________________________

How did you hear about Cassiopeia’s Bellydance? ______________________________________

Have you had any previous dance?   Yes /  No   Types of previous dance _____________________

Would you like to be on Cassiopeia’s Bellydance  mailing list?      Yes / No 

Please check the classes you are enrolling in-

SUNDAY – Starting November 4, 2007 

Beginning 1:30-2:30p___________  Intermediate */Advanced* :  2:30p-3:30p__________ 

Drop-in.  Due at beginning of each class  $12.00. ______ 

1 class/week monthly flat fee  $40.00. ______ 2 classes/week monthly flat fee $72.00 _______

Monthly fees are due the first day of each month and are valid for that month only.    

I, __________________________ have enrolled in a program of physical activity, offered by Cassiopeia’s Bellydance at Fit Sisters Gym.  I hereby affirm that I am in good physical condition and do not suffer from any disability that would prevent or limit participation in this exercise, dance, or any other activities on the premises. I, for myself, my heirs and assigns, hereby release Cassiopeia’s Bellydance and Fit Sisters Gym, the owners/directors, their families, employees, or the owner of 1715 Broadway , Vancouver WA, from any claims, demands and causes of action arising, from my  participation in any of the above stated program. I hereby release Cassiopeia’s Bellydance, Fit Sisters Gym, the owners/directors,  their families, employees, or the owner of 1715 Broadway, Vancouver WA from any liability now or in the future for any injuries participation in any other the above stated programs offered by Cassiopeia’s Bellydance or at any time, while in the vicinity of Fit Sisters Gym or in any activity sponsored, represented or organized by Cassiopeia’s Bellydance. I also understand that photos and videos may be taken throughout the year and these images may be published or used for advertising and promotional purposes by Cassiopeia’s Bellydance and /or Fit Sisters Gym, and its agents. I understand I will not be able to protest any suchuse or receive compensation of any type for use of these pictures. By signing, I hereby affirm that I have read & fully understand & agree with the above waiver.

 _____________________________________________________________ Date___/____/____

Signature of parent or legal guardian, if student is under age 18yrs. Print and bring to first day of class.  Visit www.bellyrolls.com for more information, updates and credit card payments.