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Metamorphosis Belly Dance Studio

Metamorphosis Belly Dance Studio 1108 Jackson Street Omaha, NE 68102 402-707-2508 www.metamorphosisbellydance.com Belly Dance & POI Instruction Registration/Release Form Class Belly Dance Please place a check mark by the class you wish to take.         Monday- 10:30am. to 11:30am.         Saturday-11:00am. to 12:00am . .  Beginning classes         Monday- 6:30pm. to 7:30pm.         Tuesday- 6:30pm. to 7:30pm.         Wednesday- 6:30pm. to  7:30pm.                   Saturday- 9:30am. to 10:30am. Intermediate classes          Tuesday-  8:00pm. to 9:00pm. .         Wednesday- 8:00pm. to 9:00pm. Advanced classes          Monday- 8:00pm. to 9:00pm.                Saturday- 12:30p.m. to 1:30p.m. Student Name: Address: City : State: Zip Code: Home Phone: Cell: E-Mail Address: Student Age (if  under 18) Parents name Home Phone: Cell: E-Mail Address: Emergency Contact Person’s Name Phone Number: Alternate Phone# Medical Information (allergies, medical conditions, medications: if none please write “NONE”) Doctors’ Name:  Phone: I                                                                                                                                  hereby forever release Metamorphosis Belly Dance Studio, and all associated instructors and/or staff from any and all responsibilities and/ or liabilities incurred for any I injuries or pre-existing medical conditions in association with any level of belly dance instruction classes, practices, or workshops held at Metamorphosis Belly Dance Studio or performances held in conjunction with Metamorphosis Belly Dance Studio.  I furthermore understand that these classes may be photographed and/ or videotaped  for promotional matters, and agree to said photography and or videotaped as a condition of my participation and release all interest in such media. I understand that payment is due upon registration of classes or at the time of the first class session. Registration fees are non-refundable.  All return checks are subject to a $25.00 service fee will be applies to all return checks.         Student Signature: Parent Signature ( if applicable)  

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