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

IMPORTANT NOTICE FOR THE MONTH OF JULY!!!!!!!!!!!!!!!!!!!!!!!
**Send all registration forms to Nichole Frechette (Zabel)
isis913@hotmail.com or 34 Green Rd Amherst NH 03031

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 **