MIDDLE EASTERN DANCE - STUDENT REGISTRATION

 

Please fill in the following form and click the "Submit" button at the bottom:
 

Name :

 

Street Address:

 

City:

   State:    Zip:  

Telephone:

*E-mail :

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

Class choice:

 

 

Please read the following:

Discounted fee is non-refundable and is not transferable toward subsequent sessions in the event of missed classes.  Combination classes available to advance students only.

Combination classes available to Beginner II, Intermediate, and Advanced students only...please inquire about specific guidelines for instructor approval.

I understand that belly dancing can be strenuous physical activity, and that I should consult my physician before beginning any new exercise program and that the instructor, Paula Reid Stump, and studio location, Raks Sharki Studio-Wake Forest University Reynolda Village, accept no liability for any injury or problems resulting from the exercises in this class.

Do you agree to the above terms?            yes    no

 

Status:

Children:    Ages:

Pets:  Describe:

Your Birthdate:  Example (mm/dd/yy)  

Occupation and Place of Employment:

Hobbies/Special Interests:

Any past dance or theater experience or training? Yes No

If Yes, please describe

Do you play any musical instruments? Yes No   If yes, please describe

Do you have any physical constraints, illnesses or past injuries?  If yes, please list below.

How did you hear about my class and/or web site?

Why do you think you want to take "belly dance" lessons?

What does your spouse, significant other or your family think about you learning to "belly dance'?

Have you ever seen a performance or show by an authentic or professionally trained belly dancer (e.g. Middle Eastern Restaurant, Cabaret or Festival)? Yes   No   If yes, please describe below:

Do you have any concerns or questions?

Are you interested in continuing lessons and perhaps joining a troupe? Yes No Don't know.

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