Dance by Samora Class Registration Form
Class Location: Atlanta
Fusion Belly Dance
1015 Collier Rd. NW, Suite B
Atlanta, GA 30318
Class you are Registering
for (Start Date and Time): ______________________________________Health Conditions or Restrictions:_________________________________________________________________*Those with medical conditions are advised to get doctor's permission before participating in this, or any other
Waiver: By signing below I agree to participate in classes with Belly Dance by Samora at my own risk. I acknowledge
that there is a risk of injury associated with participating in these belly dance classes, as with any other physical
activity. I hereby waive, release, discharge and covenant not to hold Belly Dance by Samora and any affiliates responsible
for any injury that may occur while taking classes or as a result of participating in class. I also acknowledge
that Belly Dance by Samora is not responsible for anything lost, stolen or damaged while I am taking classes at Several
Dancer's Core (hereafter "SDC"). Additionally, I hereby agree to indemnify Belly Dance by Samora
for any damage that I personally cause to the premises/studio. I understand that Belly Dance by Samora does not own,
operate or manage SDC; but instead leases studio space from SDC as an Independent Contractor.
that I am signing up for participation in a six week course and not for individual classes. Therefore, I am responsible
for paying the entire amount for the course whether I attend all six classes or not. I understand that I am entitled
to a full refund prior to the start date of the course if I request one in writing from Belly Dance by Samora.
After the first day of class, I understand that I will not receive a refund. I can, however, request a partial
refund after participation on the first day of class (all but $15 of your course fee will be refunded) if I change my mind
about taking the class; but I must make a request for the partial refund that day (first day of class). After the
first class, my right to any refund is waived.
I have read and understood this waiver of liability, assumption of
risk and indemnity agreement and am signing freely, knowingly and voluntarily. I further attest that I am at least eighteen
(18) years of age.
Please print and mail completed registration form and payment ($60 if registration received
prior to class start date, $70 thereafter) to:
Belly Dance by Samora
1464 Gates Circle SE
Atlanta, GA 30316