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 - Wednesday 7-8pm $55 per Six week-session Beginner Basics - Wednesday 7-8pm $15 per lesson Intermediate - 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:

September 2, 9, 16, 23, 30; Oct. 7
October 14, 21, 28; November 4, 11, 18  

CAPTCHA Code:*

Powered by Fast Secure Contact Form