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Zumba Fitness Registration Form


To speed registration on the first day of class, please print and fill out this page and bring it with you.

DUMFRIES YOUTH CENTER

ZUMBA® Fitness Registration
(separate application required for each person)
 
Session Three
Participant Name:___________________________ 
DOB:___/___ (Mo/Day) Sex:_______
    
Address:__________________________________________
City:________________State:____ Zip: _______
E-mail:_________________________________
 
Phone (H):_____________ Phone (W): _______________
Phone (C): ____________________
 
Please circle the best way to contact you in case of class cancellation.
 
In Case of Emergency, please contact: Name:_________________________________________
 
Phone: __________________________
Relationship:__________________________________
 
Are you taking any medications or have any medical conditions that the instructor should be aware of:(   ) YES   ( ) NO If yes, please list: _______________________________________________________
 
 
SIGNATURE:____________________________________________ DATE:_________________
 
 
Thank you!    Gracias!   Mercei Beaucop!    Ngiyabonga!    
M goi!   Danke!   Ahsante!
 
 
 

For Office Use Only
Number of Classes
 
Method of Payment
 
Personnel Initials and Date
 
Other
 

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