Mystic Beach Butoh
Registration

*Name:

*Address:

*City:

*Province:

*Postal Code:

Day Phone:

*Evening Phone:

*Email:

Date of Birth

Please describe your dance training / experience to date:

Allergies:

Do you have any physical or health conditions that we should be aware of?

Please read the following:  Your registration confirms that you are aware that participation in movement workshops and other physical activities involves a risk of normal injuries associated with that participation. Your involvement in this workshop demonstrates of your acceptance of such risks and your understanding that the Dance Victoria Society, Kokoro DanceTheatre Society and Lynda Raino Dance accept no responsibility for such normal activity-related risks.

I agree.

$50 registration deposit

pay deposit using PayPal (payment button will appear on the next page after submitting your registration)

I'd rather pay your deposit by cheque:

Make cheque payable to Dance Victoria
Mail to:
Dance Victoria
2236 Hampshire Tce.,
Victoria , BC V8S 3G9

We will confirm your registration upon receipt of the cheque.