ASA! with Dara  
ASA! – An upbeat, high energy, low impact dance fitness program fusing modern African club dance movements and exercise science designed for participants of any level. The movements of an ASA! Routine target the core stabilizing muscle groups that allows participants to improve their endurance, cardiovascular capacity, burn calories, tone  and have fun!
Sign in to Google to save your progress. Learn more
Email *
Phone Number
Sign me up for: *
Required
Participant Information
Provide your name, verify that you are 18+ years old, and provide an emergency contact.
Participant's Full Name *
I certify that I am at least 18 years old. *
Required
Emergency Contact Name and Phone Number
Class is held at The Adinkra Cultural Arts Studio, 3804 34th Street, Mt. Rainier, MD 20712.  Please select your preferred method of contact in the case of class cancellation. *
After selecting your payment option, tap & hold the image to make your payment.  *
Waiver of Liability & Release
PLEASE READ THE FOLLOWING AGREEMENT AND WAIVER CAREFULLY, AS THIS AGREEMENT INCLUDES RELEASE AND WAIVER OF LIABILITY, AN ASSUMPTION OF RISK AND AN AGREEMENT TO INDEMNIFY THE RELEASEES. BY PROCEEDING WITH REGISTERING FOR THIS PROGRAM, YOU ACKNOWLEDGE AND AGREE THAT YOU HAVE CAREFULLY READ THE AGREEMENT AND WAIVER AND AGREE TO THE TERMS SET FORTH BELOW.


ASA! Class Waiver. I acknowledge that this ASA! dance fitness class involves strength, bodyweight, flexibility, aerobic, cardio and other exercises all of which can be potentially hazardous activities. I am voluntarily agreeing to participate in the ASA! dance fitness class and I hereby agree to expressly assume and accept any and all risks of injury, physical harm or death. I acknowledge and represent that I am physically sound and I do not suffer from any illness, impairment, disease or other condition that would prevent me from participating in the ASA! dance fitness class, performing any exercises or using any equipment. In consideration of being allowed to participate in the ASA! dance fitness class, I do hereby knowingly and voluntarily, on behalf of myself and my heirs and assigns, forever waive, release, discharge and hold harmless the ASA! instructor, the ASA! Enterprises company, its subsidiaries and affiliates and each of its respective employees, agents and representatives, each of their respective successors and assigns, individually and collectively, from any and all liability, damages, losses, suits, demands, causes of action (including, without limitation, negligence) or other claims of any nature whatsoever, including without limitation any losses for property damage, personal injury or death, arising out of or relating in any way to my participation in the online ASA! dance fitness class and its related programs and activities or my use of any facilities, equipment or machinery in connection with the ASA! dance fitness class.I hereby consent to receive medical treatment, which may be deemed advisable in the event of injury, accident, and/or illness during the ASA! dance fitness class. I represent and acknowledge that I have read and understand this ASA! Liability Waiver and Release Form. The invalidity, in whole or in part, of any portion of the above paragraphs will not affect the remainder of this form. My voluntary execution of this form evidences my agreement to the terms, provisions, waivers and releases as set forth above. *
Required
Photo Release
I hereby permit Dara Yah'ya  to publish photo, video image and/or interview of me  taken while I participate in a ASA! class.  I understand that this material may be used to promote ASA! activities in various ways including distribution on the internet. I understand that I will receive no remuneration for the use of this image *
Required
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms