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Membership Agreement
Dear Student, welcome to our Harakat Family!
A place of wellbeing, fitness, art, dance, fun and women empowerment.
.
Take a few minutes to fill up our membership agreement.
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PART 1 - Personal information
Enter your full name
*
Your answer
Is the Student a minor?
*
yes
No
If your answered YES to the previous question.
Name of the parent or guardian
*
Your answer
TAKE NOTE
To all the parents or guardians of students under the age of 18 years old.
By filling up this form you are agreeing to all the terms and conditions of this membership.
ID
*
Your answer
Address
*
Your answer
Phone number
*
Your answer
email address
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
In case of emergency, contact:
(Name and phone number)
*
Your answer
Do you have any physical or medical condition which can prevent you from doing any form or physical activity? IF yes, please elaborate.
Your answer
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