Healing Rhythms
A Dance Movement Therapy Class
Permissions for Disclosure : *
*Our dance classes are videotaped and photographed*. I grant ESSENCE OF MIND OUTREACH permission to record and/or/photograph/include me in the recorded dance sessions and allow/ONLY use it for the sole means of advertising the dance class to the public and reporting progress to the CITY OF BRAMPTON as well those who have registered for the class to access it. Please put your initials below.
Name *
Mailing Address
Age *
Email *
Phone Number *
What is your main reason for registering for this class? *
Have you been clinically diagnosed with any of the following Mental illness disorders ? *
I identify my ethnicity as :
What do you hope to accomplish by taking this dance class ? *
Favourite Genre of music
How did you hear about this class? *
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