Bellydance with Zaina

**For Zaina and studio use only – will not be shared**

Date: _____________________________________________________________

Name:_____________________________________________________________

Address:___________________________________________________________

City&Zip:___________________________________________________________

Phone Home:_________________________ Cell:__________________________

E-Mail: ____________________________________________________________

Dance background:__________________________________________________

Where did you hear about class?

A friend: __________________________________________________________

Pelham City Newsletter:_____________________________________________

Grebel Dance Studio: _______________________________________________

Internet Source:____________________________________________________

(Which one? Bellydancewithzaina.com, Active Culture, etc…)

Other:____________________________________________________________

$50 per session To be paid in cash on first night of class

WAIVER

Use of the facilities and participation in dance or other physically demanding activities inherently exposes the participant to certain degree of risk of personal injury, illness, and other adverse medical consequences. The facility/individual instructor is not an insurer of a member's life or personal safety. No individual will engage in activities that, which require a level of physical fitness exceeding his/her physical condition or abilities, as determined by the individual. Every person assumes the risk of personal injury, illness, or other conditions arising out of or related to the individual's activities on facility premises and releases the facility/individual instructor, its directors, officers, agents, and employees from all claims, actions, or liability on account of such causes.

Initial________