Introductory class registration form

 

Name: Name is required.
Address:
Street address is required.
City:
City is required.
State:
State is required.
Zip:
Zip is required.

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Email:
Email address is required.

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Phone:
Phone number is required.
Emergency contact:
Name: Phone:
Registering for:
(6 classes, $120): Please make a selection.
        Tuesday 6:30pm-7:30pm, 8:00pm-9:00pm
        Thursday 8:00pm-9:00 pm
        Saturday 10:30am-11:30am (4 classes, $120): Please make a selection.
        Tuesday 9:30pm-11:30pm
        Thursday 6:30pm-8:00pm

Approximate date you would like to start: Please enter a start date.
(you will be notified of actual start date)

Please list any medical conditions, allergies, etc. that we should be aware of:

Release of Liability

In consideration for participation in the above classes, participant agrees to assume all risk of personal injury, loss, or damage to property. The participant also agrees to hold harmless and indemnify the American Chinese Cultural Service Inc. doing business as Dragon and Crane, their respective directors, officers, agents, instructors, and employees from any and all claims, action, injuries, or damages which may be sustained or caused by participant in connection with these activities.

Refund Policy

Tai Chi and Shaolin are ongoing classes so you may start on any day the class is held, but you must take the remaining introductory classes within 60 days after your first class. No refunds are given for any classes not taken within the 60 day period.

Please check to indicate agreement. I understand and agree to the Release of Liability and Refund Policy.

Payment is by credit card only. Please call Jasmine at 914-669-0888 to pay by credit card before your first class.