Registration Belly Dance Basics DVD Student Registration For All Class Offerings * indicates required field Name:* Email:* Street Address: City: State: Zip Code: Telephone:* Class Choice: Beginner Basics - Monday 5:45-6:45pm $55 per Six-week Session Beginner Basics - Monday 5:45-6:45 $15 per lesson Beginner Basics - Wednesday 7-8pm $55 per Six-Week Session Beginner Basics - Wednesday 7-8pm $15 per lesson *Troupe Class - Wednesday 6-7pm $55 (6 weeks) Do you agree to the above terms?* Yes No Status: Married Single Divorced Widowed Other Children: Age(s) of Child(ren): Pets: Describe Pets: Your Birthdate (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? yellow pages, internet search, newspaper/magazine ad. If referred by friend please list name): Do you have any concerns or questions? Are you interested in continuing lessons and perhaps joining a troupe? Yes No Don't Know Please confirm Beginner Basics session (beginning date) for which you are registering: Jess: Mar. 8, 15, 22, 29; Apr. 5, 12 Gypsy: Mar. 3, 10, 17, 24, 31; Apr. 7 CAPTCHA Code:* Powered by Fast Secure Contact Form Payment Option Beginner 6-Weeks Session $55.00 USDPer Lesson $15.00 USDPunch Card (11 lessons) $100.00 USDPrivate Lesson $65.00 USD