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 & Open Level w/Jess - Saturday 10am - 11am Class Card: 3 minimum at $10 per class (no expiration date) or $15 per lesson (drop in) Basic Fundamentals w/Gypsy- Wednesday 6-7pm; $60 per six-week session -or- $15 per lesson Troupe Class w/Gypsy (by invitation) - Wednesday 7-8pm; $60 per six-week session -or- $15 per lesson 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: Gypsy (Wednesday): January 11, 18, 25; February 1, 8, 15 Jess (Saturday): to be announced CAPTCHA Code:* Powered by Fast Secure Contact Form Payment Option Beginner 4-Weeks/Month $50.00 USDPer Lesson $15.00 USDPrivate Lesson $65.00 USD