Full name _______________________________________________
Address _______________________________________________
Address _______________________________________________
Home phone _______________________________________________
Cell phone _______________________________________________
Email address _______________________________________________
I understand and acknowledge that at Samadhi’s belly dance classes, I will be
treated like an intelligent and responsible adult. As such, I will be expected to be
aware of the nature of our activities, to be aware of my own physical condition and
limitations, and to take full responsibility for my own actions and participation in all
activities. I will be mindful of my own safety and the safety of others in the group.
I understand that Samadhi does not provide medical or accident insurance
coverage or insurance for loss of personal property and that I am responsible for
this.
I submit that I have not been told not to engage in belly dancing or any other
physically strenuous activity by a doctor. If I have been given physical restrictions
by my doctor, I will provide a copy of those restrictions to Samadhi and will adhere
to all of those restrictions.
I assume all risks and hazards incidental to my participation in this class, and do
hereby waive, release, absolve, indemnify and hold harmless Samadhi for any
claim arising out of injury to myself or others or personal loss.
___________________________________________ _______________________
Signature Date
