Registration Form for Bellydance with Kristie

Please fill in the following form and click the "Submit" button at the bottom.  To complete registration submit payment through Paypal on the class information page.
(You do not need a paypal account to use this feature) 

Name :

 

Street Address:
Apt. or box #


City:

   State:    Zip:  

Telephone:

Day Evening

*E-mail :

 * (required if you wish to get an e-mail reply)

Class choice:

 

  

Please read the following:
The movements and exercises in this belly dance program are challenging and strenuous. Consult with a physician before beginning this or any other exercise program. Participant acknowledges as of date signed that Kristie Staton, Graphically Speaking Design Company, and Joseph K. Opperman Architechts disclaim any liability for injuries that may result from participation in this class.

Do you agree to the above terms?            yes    no
 

Reasons for interest in the dance:

Other interests:

How did you hear about this class?

Do you have any concerns or questions?

 

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