Rochester T'ai Chi Ch'uan Center

Class Registration Form

Please read all the information carefully before filling out this form.

Payment is due upon registration.
Use this form for one person only.
Please include both day and evening telephone numbers so we may contact you.

ALL REGISTRATIONS ARE FINAL. No refunds will be given with the following exception: If a course is canceled or filled, your registration fee will either be refunded or credited toward a future course at your request.

TUITION Wm. Chen Short Form (first 20 moves) is offered as an introductory course @ $ 88 for the first 10 weeks. All subsequent classes are $110 for 10 weeks.

Family Discount: 1st member- full price; two or more members- deduct 15% (does not apply to introductory courses)

Health Insurance Discount: Discounts may apply for various providers.

Name:		Day Phone:
Address:		Evening Phone:
Address:		E-Mail Address:

**WHERE DID YOU HEAR ABOUT THE ROCHESTER T’AI CHI CH'UAN CENTER? * *

Website Yellowpages Newspaper

Poster (Location) Personal referral

Employee newsletter (company)

Health Insurance Benefit (company)

Other

LIABILITY WAIVER

I agree to waive claims against any persons and the facility connected with this(these) event(s) for injuries I may sustain and likewise assume full responsibility for all my actions in connection with said event(s). I understand that any pictures of me participating in said event may be used for publicity without compensation. I have read and fully understand all terms explained above.

SIGNATURE:
by reentering your name here you indicate that you authorize this form.