Space Coast Raks Registration

presented by Hip Motions

Please pay, fill out this Registration form, and sign below prior to the event.

Pay for Space Coast Raks

Name

First Name

Last Name

Birth Date

YYYY

Gmail (if you have Google)

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile Number

Facebook Name

Instagram Name

Which Options have you registered for?

Please Specify (example: Universe Package, Sat only, 5 show tickets, whatever you purchased)

Welcome and Thank You!

Belly Dance is a safe and gentle activity as well as a great way to move! To ensure you have the most positive experience possible, please answer the following questions below. Please elaborate in the box below.

Previous or current pain or discomfort?

Type Yes or No. If yes, in what movements or positions.

Disclaimer: I agree that I am participating in this session under my own responsibility and I will not hold Jacqueline Gonsalves, Nadirah Johara, facilitator(s) Hip Motions, LLC or any facilities in which classes are taught liable for any damage, injury or misfortune that may occur. I understand that it is my responsibility to consult a health car practitioner regarding my ability to participate in belly dance classes, before taking part in this session. Participants under the age of 18 must have parental consent and signature.

Signature

Guardian Signature

Date

YYYY

Space Coast Raks Registration

Please pay, fill out this Registration form, and sign below prior to the event.

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