Class Registration Form

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Copy and paste the registration form into a word document and fill out the information. Then attach it in an e-mail and send to lareinal@earthlink.net or fax it to 781-306-1333 or send it via snail mail to Lorraine Lafata 14 Kilsyth Rd #1 Medford MA 02155

Sacred Source Dance Studio Registration Form

Please complete the following information and return to Lorraine Lafata at 14 Kilsyth Street, Medford MA 02155

Name (Last, First):________________________________________________________
Date of Request: ______/______/_______

Circle one:
Returning Student New Student

E-Mail Address: _______________________________________________________
Telephone Number: (______)________________________________________________
Work or Cell Phone Number: (______)________________________________________
Mailing Address (please include town, state and zip): ____________________________ _______________________________________________________

How did you hear about us?
Friend Newspaper Flier E-Mail Website Other:____________________

Would you like to be on our E-mail list?
Yes No

Class or Classes you are signing up for:
Absolute Beginner Belly Dance
Beginner Belly Dance
Adv. Beginner Belly Dance
Intermediate Belly Dance
Adv. Belly Dance
Other:________________________________

Season of Class you are taking:
Spring Summer Fall Winter

Total Amount Paid for Class:___________________________
Form of Payment:____________________________________

** NOTE: When you copy and paste the registration form into a word document make sure you change the font color from white to black **