Registration Form

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Format: (000) 000-0000.

Email

example@example.com

Price List

Select all that apply

Check any/all that apply

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

Credit Card

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.&#13;&#10;The completion of this form acknowledges participants may be photographed for marketing and advertising purposes as applicable.&#13;&#10;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.&#13;&#10;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.&#13;&#10;

Date

Signature

Registration Form

Kukuwa® Baltimore

My Products

Credit Card