BELLY DANCE CLASS REGISTRATION FORM
Learn the Joyful Art of Belly Dance ...with Victoria
Belly Dance Basics and Beyond Basics Classes
at Place Concorde, 7515 Forest Glade Drive, Windsor, Ontario

Belly Dance Basics- Tuesdays 6:00 pm - 7:15 pm
Beyond Basics- Tuesdays 7:30 pm - 9:00 pm

1 Session (7 weeks) = $100.00 Can
2 Sessions (14 weeks) = $180.00 Can

~Cost includes one Basics or Beyond Basics class per week
~Discount Available for Mother/Daughter Registrations (Minimum Age=13 with Mom; 16 without Mom)
~Sorry, no refunds after 1st class

For more info, please send email to victoria@shimmycrazy.com
To register, please print this page, complete, and contact me for further instructions:
Please check as appropriate:

____ Basics
____ Beyond Basics

____ $100 1 Session (7 wks) (Mother/Daughter $90 ea)
____ $180 2 Sessions (14 wks) (Mother/Daughter $160 ea)

Name:_______________________________________________________________

Address:_____________________________________________________________

City: ______________________________ Postal Code: ______________________

Home#_____________________________ Cell#:____________________________

Work#:__________________________________

Email Address:________________________________________________________
*This information will not be shared & will only be used for classes & events*

I recognize the risks of physical injury inherent in dance and training and I am willing to
assume those risks. I agree that I will not make Victoria Currie, Place Concorde, or any
faculty member or employee of this organization liable for injuries sustained or illness
contracted by me while in class or otherwise.I agree to indemnify Victoria Currie, Place
Concorde and its employees of liabilities, costs, and judgments arising from acts of
omissions of the undersigned, which result in injury or damage to any person or party.

Signature: (Required)___________________________________________________

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For Admin Use Only:
Amount Paid ____________ Payment Method _______________ Session __________