Bellydance Class Registration for Mondays at Dance Fxbg with Amy "Kiyaana"
Please complete this form to sign up for Amy "Kiyaana" Limbrick's 7 pm or 8 pm class held on Monday nights at Dance Fxbg (Eagle Village on Rte 1). This registration will save a spot for you in the class (space is limited).

Payment can be made directly to Amy or via PayPal. Please note that refunds are not possible once the class session has started. If paying via PayPal, find buttons here http://www.kiyaana.com/pay-for-monday-classes

First Name
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Last Name
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Phone Number
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Email Address
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Emergency Contact Name
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Emergency Contact Phone Number
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Do you have any specific physical limitations? (If "yes," please describe.)
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Liability Disclaimer: Bellydance is a physical activity. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in bellydancing and/or exercise classes. I represent that I am in good health and suffer from no physical impairment that would limit my participation. I understand that I am participating in bellydance at my own risk. I agree that Amy "Kiyaana" Limbrick is not liable for any personal injury that I may suffer during class or at any related function. I hereby agree to the above conditions. (Please type your name as your signature to affirm this.)
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