Registration Form

Please complete the following form and click the submit button to register. Please bring your payment to the first class.

Welcome to bust-a-groove!! If you have any further questions feel free to contact us.

*Please Note: We collect personal information to be able to inform you should a class be cancelled or, in the case of emergency contact, to reach someone during class if an emergency arises. We will not contact you with email updates unless you click 'yes' to be added to our database. We do not share your personal information with any third parties.

First & Last Name:

Address:

City:

Province:

Postal Code:

Phone No. Day:

Phone No. Eve:

Email Address:

Preferred means of communication:
Email
Phone Day
Phone Eve

Emergency Contact First & Last Name:

Emergency Phone No.:

Class Location:

Form of payment (*please bring your payment with you to the first class):
Cash
Cheque

Please list any health issues you may have:

Would you like to receive email updates and information from bust-a-groove? (*Please note: we do not send out notices often - we abide by a strict 2-4 emails per month maximum)
YES
NO

Release & Waiver

In consideration of bust-a-groove motivational dance accepting this application, I, the undersigned, release bust-a-groove motivational dance, its respective servants, agents, or employees from claims, demands, damages, actions, or causes of actions arising out of or in consequence of any loss, injury or damage to my person or property incurred while attending at or participating in a motivational dance class notwithstanding any such loss, injury or damage may have arisen by reason of the negligence of bust-a-groove motivational dance, its servants, agents or employees.

I further state that I am in proper physical condition to participate in any and all of those activities, which I choose to engage in while at bust-a-groove motivational dance, and am aware that participation could, in some circumstances result in physical or medial injury or aggravation of an existing physical or medical condition.

Without limiting the generality of the foregoing, I further release any recourses, which I may now or hereafter have resulting from any decision of bust-a-groove motivational dance.

This release and waiver shall be binding upon for myself, my heirs, executors, administrators, personal representatives and assigns.

Note: you must click 'I accept' this release and waiver to register fora  bust-a-groove motivational dance class.


I ACCEPT
I DO NOT ACCEPT