PAYMENT THROUGH PAYPAL
ON THIS PAGE IS FOR
NEW STUDENTS ONLY.
Price List & Class Descriptions Are On Our Class Schedule Page...
Please copy & paste this form & bring with you
City: _______________________ State: __________ Zip Code:______________
Home Phone:_______________________ Cell:___________________________
Birthday: Month:____________________ Day: _________Year:___________
DL Number: _______________________________________________________
In Case Of Emergency (Name & Number)____________________________
Please Check Which Classes You Are Registering For:
BELLY DANCE & GYPSY FUSION
____ABC's of Belly Dance ___Tuesday Advanced
____Crescent Moon Dance Co._____ Wednesday Beginner
____Wednesday Intermediate___ Thursday Intermediate
____Thursday Beginner_____Saturday a.m. Beginner
____Saturday a.m. Intermediate_____Gypsy Fusion
___ Monday Walk & Step (30 Minutes)
___ Wednesday Abs & Waist (30 Minutes)
___ Monday Yoga/Pilates (30 Minutes)
___Wednesday Yoga/Pilates (1 Hour)
___ Monday Grown & Sexy ___ Monday Advanced____Sat. Beginner
How Did You Hear About Us?______________________________________________
WAIVER OF LIABILITY & HOLD HARMLESS AGREEMENT
1. In consideration for participating in classes and other valuable consideration, I hereby RELEASE, WAIVE, DISCHARGE AND CONVENANT NOT TO SUE Crescent Moon Belly Dance Studio, Inc and its owner/operator, officers, servants, agents, and employees (hereinafter referred to as RELEASEES) from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES, or otherwise, while participating in such activity, or while in, on or upon the premises where the activity is being conducted or in transportation to and from said premises.
2. To the best of my knowledge, I can fully participate in this activity. I am fully aware of risks and hazards connected with the activity, including but not limited to the risks as noted herein, and I hereby elect to voluntarily participate in said activity, and to enter the above-named premises and engage in such activity knowing that the activity may be hazardous to me and my property. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS, PROPERTY DAMAGE OR PERSONAL INJURY, INCLUDING DEATH, that may be sustained by me, or any loss or damage to property owned by me, as a result of being engaged in such an activity, WHETHER CAUSED BY THE NEGLIGENCE OF RELEASEES or otherwise.
3. I further hereby AGREE TO INDEMNIFY AND HOLD HARMLESS THE RELEASEES from any loss, liability, damage or costs, including court costs and attorney’s fees, that may incur due to my participation in said activity, WHETHER CAUSED BY NEGLIGENCE OF RELEASEES or otherwise.
4. It is my express intent that this Release and Hold Harmless Agreement shall bind the members of my family and spouse (if any), if I am alive, and my heirs assigns, and personal representative, if I am not alive, shall be deemed as a RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE the above named RELEASEES. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of Texas.
5. I UNDERSTAND THAT CRESCENT MOON BELLY DANCE STUDIO, INC. WILL NOT BE RESPONSIBLE FOR ANY MEDICAL COSTS ASSOCIATED WITH ANY INJURY I MAY SUSTAIN.
6. I further agree to become familiar with the rules and regulations of the Studio and not to violate said rules of any directive or instruction made by the person or persons in charge of said activity and that I will further assume the complete risk of any activity done in violation of any rule or directive or instruction.
7. I ALSO UNDERSTAND THAT I AM RESPONSIBLE FOR ANY DAMAGE I CAUSE TO THE STUDIO.
8. IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT I have read the foregoing Waiver of Liability and Hold Harmless Agreement, understand it and sign it voluntarily as my own free act and deed; no oral representations, statements or inducements, apart from the forgoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this Release in full, adequate and complete consideration fully intending to be bound by same.
Tuition is due the last class of the month. If you cannot be here, please mail it in or call it in. Otherwise, there will be a $10.00 late fee.
IN WITNESS WHEREOF, I have hereunto set my hand on this ______day of __________, 20___
Payment On This Page Through PayPal Is For New Students Only-Thank You
Please Make Sure You Pay Your One Time
Registration Fee As Well As Your Tuition.
We Look Forward To Seeing You Soon!