Intermediate Bellydance with Accalia Registration Form

Event Timing: January 21st - May 13th, 2018 / Sundays at 6pm
Event Address: 109 Pulford Street, Winnipeg, MB
Contact us at

Drop-in rate: $17/ class
Full session rate: 4 x $50 for 16 weeks of classes ($12.50/ class)

Name *
Your answer
Email *
Your answer
Emergency contact person - name *
Your answer
Emergency contact - phone number *
Your answer
Dance Background *
I understand the following; My spot in this class is reserved only upon the completion of registration. Registration is complete only upon the submission of this form AND the payment of $50 by eTransfer to *
What do you hope to learn and / or achieve during the Intermediate Class? (optional)
Your answer
I am 18 years of age or older *
If participant is under 18 years of age, this online registration form will not apply. Underage participants will have to register in person, with permission of a parent or guardian. Email for more information.
Participant risk acknowledgement, release, waiver of claim and assumption of risk for Bellydance Classes with Accalia and use of the dance class facilities.
I agree and acknowledge that:
1. I am aware that there are risks and hazards inherent in learning a new style of dance. I am aware that I may participate only to the extent that I personally decide to, and therefore, I voluntarily and freely assume the risks of my participation in Bellydance Classes with Accalia.
2. I hereby release and forever discharge and hold harmless Accalia Robertson, the tenants of the dance class facility, the owners of the dance class facility, employees and volunteers (All hereinafter referred to as the "Releasees") of and from any and all claims, demands, damages, proceedings, expenses, actions, or causes of action in law or in equity in respect to any death, injury, loss, or damage to myself or to my property howsoever caused and arising or to arise by my use of the dance class facilities including, without limiting the generality of the foregoing, the negligence of the Releasees.
3. I agree to indemnify and save harmless the Releasees for any claim, including any claim for medical services arising from the use of the dance class facilities.
4. I am aware of the nature and effect of this Release, Waiver of Claim and Assumption of Risk, my voluntary signature on this Release, Waiver of Claim and Assumption of Risk is binding upon myself, my heirs, my executors, administrators and assigns.
5. This Release and Waiver of Claim shall be binding upon me, my heirs, executors, administrators and assigns.
6. I am executing this Release and Waiver of Claim and Assumption of Risk freely and voluntarily without any compulsion on behalf of Bellydance Classes with Accalia.
7. I acknowledge that I have read this entire Agreement prior to signing it. Intending to be legally bound I have signed this Release, Waiver of Claim, and Assumption of Risk.
I agree *
Additional Notes (optional)
Your answer
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