Nova Scotia Belly Dance

Belly Dance Class Registration Form

Instructor:  Sacha Begg

Name:____________________________________________________________

Address:__________________________________________________________

Phone:(____)______________________________________________________

Email Address:_____________________________________________________

Do you have any previous Belly Dance experience?      Yes / No                                      If yes, where?  ______________________With whom?_____________________  

What style and for how long?__________________________________________

Which class are  you registered for?______________________________________

What are your expectations or goals for this class?___________________________
_________________________________________________________________
_________________________________________________________________

How did you hear about Belly Dance Classes with Sacha?______________________
_________________________________________________________________

Do you have?
Arthritis -  Yes   No    ;  If yes, rheumatoid or osteo?                 
Heart disease -  Yes   No
High/Low blood pressure -  Yes   No ;
Diabetes -  Yes   No     Hypoglycemia   Yes    No
Epilepsy -  Yes   No
Fibromyalgia  - Yes  No
Asthma – Yes  No
Allergies - Yes   No  If yes, do you require epinephrine?  Yes    NO
Are you pregnant? – Yes   No  Are you nursing?     Yes     No

Previous injuries or surgeries -  Yes   No  If yes, please give details _____________________________________________________________________________
________________________________________________________________________________
Previous or current pain or discomfort (if yes, in what movements or positions)       Yes   No  __________________________________________________________ ______________________________________________________________________________
Are you taking any medication? If yes please list.-  Yes   No ______________________________________________________________________________
Other conditions (please specify) ______________________________________________________________________________

Disclaimer: I agree that I am participating in this session under my own responsibility and I will not hold Sacha Begg, her agent(s), representative(s), facilitator(s), studio owners liable for any damage, injury or misfortune that may occur. I understand that it is my responsibility to consult a health care practitioner regarding my ability to participate in belly dance classes, before taking part in this session. Participants under the age of 16 must have parental or guardian consent and signature.  I also understand that there are no refunds on class fees!  Special situations may be discussed with Sacha Begg.

Participant’s Signature:_______________________________  Date:__________

Guardian’s Signature:________________________________  Date:__________    
Emergency Contact : __________________________  phone: ­­­­­­­­­­­­­­­­­­­­­­­_______________

Would you like to be on my mailing list and receive annoucemnts (via email) about upcoming events and classes?_________________________________________

 What do you need for Class?

1. Please copy, print and fill out the "Registration Form" above, and bring it with you on the first night of class.  

2. Bring a bottle of water and a yoga mat or towel (because we usually do some warm up and stretches on the floor). 

3. Wear comfortable, form fitting clothing like yoga pants and a tank top.  This is so I can see your posture and movements.  No Jeans or perfume please! 

4. You do not have to show your belly, or wear a costume to class!