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________________________________
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