myBurlesque Medical/Consent Form

Venue:  Bancroft Meeting Place, Hadrians Drive, Bancroft. MK13 0QB ( this is the venue address and not  for correspondence)

Cost:    Monthly course fee £42 (non refundable)  Your place on the course is not confirmed until payment has been received. If the course is already full then a full refund will be given.

Cash or Bank Transfer Pay: M Perez-Amaro reference: myBur (and which day and month i.e Mon/Apr, Thurs/May, Wed/June)

Sort Code : 20-91-48 Account Number:70571377

Contact: MiMi via the facebook page,  email: info@myBurlesque.co.uk or text 07803 015207

Consent and Confidential Information Form

I will not hold myBurlesque or the MAPA School of Dancing liable for any injuries or Viruses I may obtain from these and subsequent workshops, this includes spankings from the teacher. I am happy for videos and photos to be used for promotions/marketing, names will not be included. 


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Email *
First Name *
Surname *
Start Date *
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DD
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YYYY
Address *
Mobile number *
Date of Birth *
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DD
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YYYY
Name of Emergency Contact for during class time *
Number of Emergency Contact for during class time
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Do you have any access needs? *
Do you have any medical needs we should be made aware of?
Name of GP Practice *
Contact number of GP Practice *
Anything other information you feel might be useful for us to know?

myBurlesque/MAPA School of Dancing has the right to cancel the course if not enough interest with a full refund given.

Please Tick that you are happy for myBurlesque/MAPA Dancing to 

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Please print name to say you are happy with our terms and conditions mentioned above *
How did you hear about us? *
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