Belly Dance with Josephina

Mid-Coast Maine Belly Dance: Creating Community through Dance

Josephina Gasca offers Belly Dance classes, performs, and hosts events in the Mid-Coast Maine area.

To Register:

Name of Participant

First Name

Last Name

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number Best to Reach You:

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Secondary Phone Number:

(###)

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Occupation(s):

Date of Birth:

YYYY

Select Season

Select Class

LIABILITY DISCLAIMER: Instructors and Facilities are not liable for personal injuries or loss of or damage to personal property. Since this is a physical activity, injuries may occur. Each student may decline to participate in any activity that they feel may be harmful; and is also responsible for informing the instructor of any physical limitations that may prevent full participation. Written approval from your physician may be required after extended illness, physical injury or accident.

By checking the box below, I certify that I have read and agree to the above stated policies.

Date

YYYY

Select Payment Option:

Please note that a $30 fee will be assessed for any returned checks.

Message to Josephina:

Please indicate here if you are signing up for less than a full session or if you have any other special circumstance to note.

How did you find Belly Dance with Josephina?

To Pay:

To pay via check, please make your check payable to the order of Josephina Gasca and mail to:

1213 Washington Street, Bath, ME 04530

To pay via PayPal, please transfer monies to Josephina.Gasca@comcast.net via your PayPal account.