Student Registration Form - Pure Soul Energy

Thank you for choosing Pure Soul Energy. Please fill out the registration form below to enroll in our classes. Once submitted, our team will reach out within 24 hours to confirm your schedule and welcome you personally!

Student Information

Name *

First

Last

Email *

Phone *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of Birth *

Parent/Guardian Information

Consents Date Liability

Name

First

Last

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Dance Styles Interested in *

Bollywood
Kathak
Bhangra
Chakradance

Experience Level *

Beginner
Intermediate
Advance

Experience

Years of Previous Training

Emergency Contact

Emergency Contact Name *

First

Last

Phone *

Medical Concerns

Consents & Agreements

Liability Waiver *

• Liability Waiver: I understand that dance involves physical exertion and risk. I hereby release Pure Soul Energy from any liability regarding injuries sustained on the premises.” [initials please]

Photo Release *

• Photo Release: “I grant permission for Pure Soul Energy to use photos/videos of the student for promotional purposes.”

Signature *

Signature [initials please]