OASIS DANCE STUDIO
CLASS AND WORKSHOP
REGISTRATION AND LIABILITY RELEASE
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PLEASE NOTE: All payments for classes and workshops, regardless of instructor, are to be made
payable to Jeri Zeigler.
Registration for (indicate which workshop/class): __________________________________________________
Name: _____________________________________ Phone Number (s): ________________
Address: ______________________________ City: _________
Zip: ________
E-mail Address: ______________________ May I add you to my e-mail list: Y N
Please tell me about yourself:
Previous Dance Experience: ______________________________________________________
Comments / what you’d most like to learn:
______________________________________________________________________________
How did you hear about this class?: _______________________________
Any injuries/health conditions the instructor should be aware of?: _________________________
_________________________________________Are you currently pregnant?:________
Emergency Contact: ___________________________ Phone Number: ___________
I, (print name) __________________________________, agree to the following:
1). I release and discharge Jeri Zeigler, the property owners of Oasis Dance Studio, and any substitute or
participating teacher from any and all liability, claim, demand or action that I may have resulting from injury, loss, or
damages arising from my participation in the belly dance class and workshops at the Oasis Dance
Studio, including loss that may be caused by the negligence of the released party.
2). I understand that to participate in dance classes and workshops with Jeri Zeigler and other instructors at Oasis
Dance Studio I must first pay for classes. I understand that fees are not refundable, exchangeable, or transferable.
3). I understand that dance and dance-related activities present a risk of injury to the participant. I understand that
there is an inherent risk of injury that cannot be eliminated regardless of the care taken to avoid injury. I agree to
assume any and all risks of injury from any cause or source whatsoever in order to participate in or allow my child to
participate in these activities.
4). I have read and recognize this agreement of release and waiver of liability as a legal contract and that, by
reading it carefully, I have complete and full understanding of its content and meaning and sign it of my own free will.
Participant signature over 18 years:________________________________ Date:____________
If the participant is under the age of 18 years:
As legal guardian of _________________________, I consent to the above conditions and terms.
Signature of Parent/Guardian:_______________________Date:______________
Printed Name of Parent/Guardian: ___________________________________________
Contact info: 717-919-8190 E-mail jazanadances@yahoo.com Website: www.jazanadances.com
Mail completed form with payment to:
Jeri Zeigler
PO Box 675
New Cumberland, PA 17070