Registration & Waiver Form

Persian Dance

Winter 2023

January – March

Age	Level	Start Date	Time	Location	Session/Price
12+	All Levels Persian Dance (Modern)	Sunday Jan 8	5:00 -6:00 pm	Russian Classical Ballet Academy 100 Sheppard Ave E	4 Sessions/ $115 8 Sessions/ $200 12 Sessions/ $275
12+	All Levels Persian Dance (Modern)	Sunday Jan 8	6:00 -7:00 pm	Russian Classical Ballet Academy 100 Sheppard Ave E	4 Sessions/ $115 8 Sessions/ $200 12 Sessions/ $275
12+	Advance Persian Dance	Sunday Jan 8	7:00 -8:30 pm	Russian Classical Ballet Academy 100 Sheppard Ave E	Fully Booked

Name(required)

Email(required)

Phone(required)

Date of Birth(required)

Choose One Class(required) 5:00-6:00 PM / 4 Sessions/ $115

5:00-6:00 PM / 8 Sessions/ $200

5:00-6:00 PM / 12 Sessions/ $275

6:00-7:00 PM / 4 Sessions/ $115

6:00-7:00 PM / 8 Sessions/ $200

6:00-7:00 PM/ 12 Sessions/ $275

Have you practiced Dance before?(required) No

Yes

Emergency contact's full name(required)

Emergency contact's phone number(required)

If yes, for how long? and What kind of Dance?(required)

Limitations/Injuries(required)

Do you have numbness/pain in any areas of your body? If yes, where?(required)

Other Details

If at any time during the class, you feel discomfort or strain, gently come out of the posture. You may rest at any time during the class. It is important in Dance that you listen to your body and respect its limits on any given day.

I, the undersigned, understand that Dance is not a substitute for medical attention, examination, diagnosis, or treatment. I should consult a physician prior to beginning any activity program, including dance. I recognize that it is my responsibility to notify my teacher of any serious illness or injury before every dance class. I will not perform any postures to the extent of strain or pain. I accept that neither the instructor, nor the hosting facility, is liable for any injury, or damages, to a person or property, resulting from the taking of the class. Those under 18 years of age must have this form signed by a parent or guardian. Please print your full name and date below.(required)

Payment Policy

All tuition is to be paid on the first week of each term. A 15% penalty will be applied to outstanding fees.

Once payment is processed, there will be no refund.

Choose one(required) I agree with all terms and conditions.*

Persian Dance

Winter 2023

January – March

Once payment is processed, there will be no refund.

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