Big Horn BellyDance

Registration Form

Please fill out this form completely.  Submit payment at the first class or mail to:

Bighorn Bellydance

526 Ray Road

Cody, WY  82414

Liability Disclaimer

I Certify that I am not aware of any physical or medical reason that would hinder or affect my participation in this program.  I further certify that any physical or medical conditions, limitations, concerns, and/or reasons have been disclosed to the instructor. 

I further agree that I will not hold the dance instructor, any assistant, and/or the building owners liable for any injuries that may occur.  This certification is considered legitimate with the submitting of this form.

Dancer Information:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
E-mail

Other Emergency Contact Information:

Name
Work Phone
Home Phone
E-mail

Beginner Class will run for consecutive 8 week sessions Monday evenings from 6:15 – 7:15 pm.

Select any of the following options that apply:

Beginner Class

Intermediate Class will run for consecutive 8 week sessions Monday evenings from 7:15 – 8:15 pm.

Select any of the following options that apply:

Intermediate Class











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Revised: 
12/10/09