Burke/West Springfield Senior Center Without Walls
Spring 2015
Last Name: ___________________ First Name: __________________________________________________
Phone (primary): ___________________________________________________________________________
Address: __________________________________________________________________________________
____________________/__________________________/__________________________________________
(City)
(State)
(Zip)
Email: ___________________________________________________________________________________
Emergency Contact: ________________________________________
_____________________
(Name)
(Phone)
Photo Release: By signing this form, I give permission to be photographed and/or videotaped by NCS or the media for use in
publicizing NCS programs and services.
Liability Waiver: I recognize that there are risks inherent in participating in recreational activities and agree to hold harmless the
County of Fairfax, Department of Neighborhood and Community Services (NCS), and their officers, employees, and volunteers from
any and all claims for bodily injury and/or property damage that result from my participation in any activity in this pilot program.
Registration Information Release: Registration information provided to the Fairfax County Neighborhood and Community Services is
public record and as such may be released under the Virginia Freedom of Information Act unless the participant specifically requests
that this information not be released. Check here ___ if you DO NOT grant NCS permission to release your information.
Signature ________________________________
Class
Date _____________________
Date and Time
Tuesday Yoga
Tues. 9:30am – 10:30am
Wednesday Yoga
Wed. 10:30am – 11:30am
Thursday Yoga
Thurs. 11:15am – 12:15am
Friday Yoga
Fri. 9:30am – 10:30am
Tai Chi (Section I)
Tai Chi (Section II)
Tuesday Line Dance Club
Friday Line Dance Club
Thursday Line Dance
Saturday Line Dance
Friday Line Dance
Basic Beginner
Friday Line Dance Experienced Beginner
Self-Defense
Hula Dancing
Tuesday ZUMBA
Thursday ZUMBA
Ballroom Dancing
Wed. 1pm – 2pm
Wed. 2:15pm – 3:15pm
Tues. 10am – 12pm
Fri. 10am – 12pm
Thurs. 10am – 12pm
Sat. 10am – 12pm
Scrapbooking
Thurs. 12pm – 2pm
Per Class $5 County Resident
$10 Out of County
Fri. 10am – 11:30am
Fri. 12pm -1:30pm
Tues. 12:30pm – 1:30pm
Wed. 10am – 11am
Tues. 12:30pm – 1:30pm
Thurs. 11am – 12pm
Tues. 2pm – 3:30pm
Free to participate (supplies to be
purchased through instructor)
Total $
Receipt Date__________ Received From_________________________________________________
Payment
Cash
Check
Amount
$
$
#
Received By________________________________