Please fill in the following form and click the "Submit" button at the bottom: Use the Tab key to move from input box to input box.
Name:
Street Address:
Telephone:
Zip:
State:
City:
*E-mail :
* (required if you wish to get an e-mail reply)
Class choice:
The discounted fee per session of classes at the Raks Sharki studio is non-refundable and is not transferable toward subsequent sessions in the event of missed classes, although Beginning Raks Sharki students may make up a missed Tuesday class in Monday's beginner class and vice versa.
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 instructors, Chris Campbell & Paula Reid Stump, and studio locations, (Central Family YMCA / Raks Sharki Studio-Wake Forest University Reynolda Village / Peak Fitness), accept no liability for any injury or problems resulting from the exercises in this class.
Please read the following:
Do you agree to the above terms?
YES
NO
Status:
Children:
Ages:
Your Birthdate: (mm/dd/yy)
Occupation / Place of Employment:
Hobbies/Special Interests:
Yes
Any past dance or theater experience or training?
No
If Yes, please describe:
Yes
No
Do you play any musical instruments?
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)? If yes, please describe:
