Shahrahzad Belly Dance On-Line Registration Form

Student's name:

Address:       Postal Code:

Home Phone:       Email:

If under 18 please fill out the following:

Birthday - Day:     Month:       Year:

Mother or Father's name:

Home Phone:      Work Phone:

Student's Medical Number:

Please specify any medical conditions:

In Case of Emergency contact:     Home Phone:      Work Phone:

Please indicate the class(es) you are registering for:
** ie. "Beginner Tuesday 7:30"

Class #1:    Day:    Time:
Class #2:    Day:    Time:
Class #3:    Day:    Time:

Payment:


              Acceptance Mark
  If you would prefer to pay with Paypal, click here

Conditions:
  • Withdrawal will only be accepted withing the first three (3) weeks of each term, and will result in a $20 withdrawal charge. No refunds or credits will be given after this point.
  • Classes subject to sufficient enrollment.

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