Full name   _______________________________________________

Address  _______________________________________________

Address  _______________________________________________

Home phone  _______________________________________________

Cell phone  _______________________________________________

Email address  _______________________________________________

I understand and acknowledge that at Samadhi’s belly dance classes, I will be treated
like an intelligent and responsible adult.  As such, I will be expected to be aware of
the nature of our activities, to be aware of my own physical condition and limitations,
and to take full responsibility for my own actions and participation in all activities.  I
will be mindful of my own safety and the safety of others in the group.  I understand
that Samadhi does not provide medical or accident insurance coverage or insurance
for loss of personal property and that I am responsible for this.

I submit that I have not been told not to engage in belly dancing or any other
physically strenuous activity by a doctor.  If I have been given physical restrictions
by my doctor, I will provide a copy of those restrictions to Samadhi and will adhere to
all of those restrictions.

I assume all risks and hazards incidental to my participation in this class, and do
hereby waive, release, absolve, indemnify and hold harmless Samadhi for any claim
arising out of injury to myself or others or personal loss.

___________________________________________        _______________________
Signature                                                                               Date