www.bodytunes.org

Student Information

Full Name: *

Date of Birth (MM/DD/YYYY): *

Age:Gender:

Address:

City:State:Zip:

Mobile Number: *

Email Address: *

Preferred Contact Method:

Text Call Email

Parent/Guardian Information (required for students under 18)

Parent/Guardian Name: *

Relationship to Student:

Mobile Number: *

Email Address: *

Emergency Contact (different from parent if possible)

Name: *

Relationship:

Phone Number: *

Class Selection

Please select the class(es) you are registering for:

Zumba (Adult) – Days/Times:

Zumba Gold (Seniors/Beginners) – Days/Times:

Zumba Kids (Ages: ) – Days/Times:

Other:

Preferred Start Date:

Previous dance/fitness experience (optional):

Health Information

Do you have any medical conditions, injuries, or physical limitations we should be aware of?

No Yes – please describe:

Are you currently under a doctor's care for any condition?

No Yes – Condition and any restrictions:

Name of Physician:

Physician Phone:

Payment Details (optional section for paper form)

Tuition Option:

Drop-in Class – Amount: $ per class Monthly Package – Amount: $ per month Session Package ( weeks) – Amount: $

Payment Method:

Cash Credit/Debit Card Zelle Check (No. )

Note: *Fees Apply. First Invoice will also have a registration fee.

For Office Use Only:

Amount Paid: $Date:

Received By:

Waiver, Release, and Consent

I understand that Zumba and other fitness activities involve physical movement and carry some risk of injury. I certify that I am in good physical condition to participate, or that my child is medically cleared to participate in the selected classes. I agree to inform the instructor of any changes in my (or my child's) health status.

I voluntarily assume all risks related to participation in classes offered by the studio and its instructors. I hereby release and hold harmless the studio, its owners, instructors, staff, and landlords from any and all liability, claims, demands, or causes of action arising out of or related to any loss, damage, or injury that may be sustained while participating in classes or events, including travel to and from such activities.

I understand that classes may occasionally be photographed or recorded for promotional or educational purposes. By signing below, I grant permission for my (or my child's) image to be used in such materials, without compensation, unless I provide written notice opting out.

Participant Name:

Participant Signature:*

Sign with Pen/MousePrint Name (Type)

Date:

If participant is under 18 *:

Parent/Guardian Name:

Parent/Guardian Signature:*