myBurlesque Medical/Consent Form 

Venue:  Monday's Roman Park Res Club, MK13 0RA Wed and Thursday's Bancroft Park Residents Club, MK13 0RA ( this is the venue address and not  for correspondence)

Cost:    Free for International Day of Dance Monday 29th April 6-7pm or Wednesday 1st May 7.30-8.30pm Monthly course fee £42 (non refundable)  Your place on the course is not confirmed until payment has been received. If the course is already full then a full refund will be given.

Cash or Bank Transfer Pay: M Perez-Amaro reference: AprMon7pm

Sort Code : 20-91-48 Account Number:70571377

Contact: MiMi via the facebook page,  email: info@myBurlesque.co.uk or text 07803 015207

Consent and Confidential Information Form

I will not hold myBurlesque or the MAPA School of Dancing liable for any injuries or Viruses I may obtain from these and subsequent workshops, this includes spankings from the teacher. I am happy for videos and photos to be used for promotions/marketing, names will not be included. 


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Email *
First Name *
Surname *
Start Date *
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Address *
Mobile number *
Date of Birth *
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Name of Emergency Contact for during class time *
Number of Emergency Contact for during class time
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Do you have any access needs? *
Do you have any medical needs we should be made aware of?
Name of GP Practice *
Contact number of GP Practice *
Anything other information you feel might be useful for us to know?

myBurlesque/MAPA School of Dancing has the right to cancel the course if not enough interest with a full refund given.

Please Tick that you are happy for myBurlesque/MAPA Dancing to 

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