Registration Form

Registration Form
Kukuwa® Baltimore

African Dance Workout w/ Chakeesha
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Email
example@example.com
Price List
$5 Registration Fee /(No Classes Included - One-time)$15 (Daily)$55 Private (Pay as you Go)
Do you have any respiratory problems, e.g., asthma, chronic bronchitis, emphysema, or any shortness in breath during exercise?Do you have sudden bursts of rapid heartbeats or any heart troubles?Do you have any pain or sensation of pressure in your chest when participating in any form of exercise?Does your heart ever beat unevenly or irregularly or skips beats?Do you take any prescription medicine on a regular basis?Do you have any blood pressure problems?Have you had any dizzy spells or do you often feel faint during exercise?Do you have a bone or joint problem, e.g., arthritis that gets worse with exercise?Do you have any back or knee problems that will prohibit you from exercising?Do you have any physical condition I need to know about before you participate in this class?
If any of the answers are checked /selected, please consult with a physician before participating in the Kukuwa® Dance Workout Class.

My Products

KUKUWA® Registration Fee Only

(Non-Refundable) Subscription Membership No Classes Included

$5.00

KDW (DAILY)

(Non-Refundable) (1) Participant Only

$15.00

KDW (Private) Pay as you Go

Unlimited (Non-Refundable) Up to (1) participant One Time Only

$55.00

Total

$0.00

By completing this form, it acknowledges your agreement in participating in the low impact/high energy dance workout program offered by KDW®. This is a (1) hour exercise program including a combination of low/high intensity dance movements and rhythms from African cultures.
The completion of this form acknowledges participants may be photographed for marketing and advertising purposes as applicable.
It also agrees to release the following from any and or all liability, such as injuries, or for any unforeseen accident while participating in classes instructed by Chakeesha Simmons-EL, any or all venues, companies, corporations doing business with Kukuwa® Instructors, classes, workshops, community events, performances and all affiliations, any member(s), organizer(s), staff, volunteer(s). This discloses any health conditions that would affect me, child/children in my care participating in this program, or that may harm other participants in the program.
This completion hereby releases and hold harmless Chakeesha Simmons-EL, KDW® and it's owners, and managers at Kukuwa®, of any liability related to injuries or accident that may occur during participation in this dance/fitness program.

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Kukuwa® Baltimore