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Your Name:
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Your Home Address:
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Your Email Address:
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Your Phone Number:
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Tell Me About Yourself: (ie. Occupation, hobby, previous dance experience,
physical limitations(if any). You may also use this box for any questions you have.
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Release of Liability: Must be checked to participate in the program.
In consideration of my participation in the Belly Dance Program, I hereby assume all risks and release
the program coordinators, instructors and volunteers from all liability whatsoever for any injuries or
accidents in connection with my participation. I intend this release and assumption to be binding, not
only for myself, but also on my family and all legal successors in interest. I hereby give permission to
the physician or medical personnel selected by program staff to hospitalize, secure proper treatment or
medication for, and to take whatever medical actions are necessary to treat me in case of an
emergency and I authorize the physician or medical personnel selected to provide treatment deemed
necessary by them. By checking the box, I have read and accepted these terms and conditions.
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