Registration for Class or Workshop

Please, save this page, or "cut and paste" , complete, and send as email to:  samra40@netzero.net     or     iarasamra@hotmail.com  

To pay with Pay-Pal send payment plus 5%  to  samra40@netzero.net    

To pay my mail, send a check or money order to:  Iara Kendrick,  1186 Blue Ridge School Rd. Fancy Gap, VA 24328.  For questions, call: 276-236-4533

NAME OF PARTICIPANT ___________________________

AGE (required for children or teens)_____________________

ADDRESS______________________________________

PHONE_________________ EMAIL:___________________

CLASS OR WORKSHOP________________________________

DAY AND TIME_____________________________________

EMERGENCY CONTACT_______________________________

SPECIAL MEDICAL ATTENTION_________________________

FORM OF PAYMENT____________  AMOUNT______________

SIGNED_________________________(guardian if student under 18)

DATE_______________

Waiver of Liability:  I hereby waive Iara Kendrick and the Moving Arts Center, and the proprietor of the Heritage Shoppe building  of all liability for lost, stolen or demaged property,  for  any injury or personal harm,  or any accident that may result from the participation of the person registered in this form in any classes, performances or other events sponsored by Iara Kendrick or Moving Arts Center

SIGNED__________________________________

DATE____________________________________