Registration for Class or Workshop
Please, save this page, or "cut and paste" , complete, and send as email to: [email protected] or [email protected]
To pay with Pay-Pal send payment plus 5% to [email protected]
To pay my mail, send a check or money order to: Iara Kendrick,
3925 Chilton Dr. Winston Salem, NC 27106 336-924-3940
or 336-775-8052
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 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
SIGNED__________________________________
DATE____________________________________