July 28th:Ecstatic Awakening Dance with Nicole

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Emergency Contact *

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Emergency Contact’s Phone Number*

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Which dance would you like to join?*

Wednesday, May 29th. 7pm

By checking the following boxes, this will confirm that you willingly consent to the following terms and conditions.*

I give permission to the licensed service provider to perform the service we have discussed/ scheduled online and will hold the service provider at Ocean Jasper Wellness harmless from any liability that may result from the service.I understand that in rare occasions, there are risks associated with receiving the service I have scheduled. I further understand and agree that Ocean Jasper Wellness and all service providers are not liable for any potential result or reaction from receiving the service.I have informed the service provider at Ocean Jasper Wellness of any allergies or medical conditions which could compromise my health and safety by receiving services with their vicinity.I release Ocean Jasper Wellness and all service providers from all liability associated with their services.

Are there certain movements that you struggle with? Ex.) bending down, bending knees, etc.?

Is there anything specific you’d like to gain from Ecstatic Awakening Dance?

In regards to your comfort level with dancing, where do you think you’d fall?

Dancing can be challenging for me, I feel uncomfortable most of the time.I feel okay about dancing but I get nervous sometimes.I like to dance but don’t do it every often.I love to dance and I usually feel very comfortable.

Signature*

Date*

Date

My Products*

JULY 28th: 7pm

$20.00

Total

$0.00

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