Belly Dance Class Waiver | Emily Belly Dance

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Cincinnati Ohio Belly Dancer & Teacher

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Emily Marie Art LLC
Liability Waiver

First Name

Last Name

Email

Date of Birth

Do you have a doctor’s permit to participate in intense physical activities?

No

Yes

Please specify anything we should know about

Initials

I declare that the info I’ve provided is accurate & complete

I hereby acknowledge this release from liability for accidental injury or illness which I may incur as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in this program.

Thanks for submitting!

Cincinnati, Ohio

Phone: (513) 372-5111

Email: emilymariebellydance@gmail.com

© 2023 Emily Marie Art LLC. All rights reserved.

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