Registration Form

Please read all the information carefully before filling out this form.

• Payment is due upon registration.
• Use this form for one person only.
• Please include both day and evening telephone numbers so we may contact you.

ALL REGISTRATIONS ARE FINAL. Students signing up for classes at the Rochester T’ai Chi Ch’uan Center are signing up for ten weeks of instruction, but should understand that a specific day of instruction each week is not guaranteed. The Center offers a number of class opportunities each ten weeks, and encourages students to attend more than one each week at no extra charge. Because the same instructional material is covered a number of times and a number of days each week, The Rochester T’ai Chi Ch’uan Center reserves the right to cancel, with notice, any specific learning time. Some Saturday and Sunday classes, for example, may be superseded by workshops or other Center activities. TUITION Wm. Chen Short Form (first 20 moves) is offered as an introductory course @ $ 96 for the first 10 weeks. All subsequent classes are $120 for 10 weeks.

Family Discount: 1st member- full price; two or more members- deduct 15% (does not apply to introductory courses)

Health Insurance Discount: Discounts may apply for various providers.

Name:		Day Phone:
Address:		Evening Phone:
		E-Mail Address:

What are your expectations and what benefits do you want from this course?

**WHERE DID YOU HEAR ABOUT THE ROCHESTER T’AI CHI CH'UAN CENTER? * *

Website	Yellowpages	Newspaper
Poster (Location)		Personal referral
Employee newsletter (company)
Health Insurance Benefit (company)
Attended Open House
Other

LIABILITY WAIVER
I agree to waive claims against any persons and the facility connected with this(these) event(s) for injuries I may sustain and likewise assume full responsibility for all my actions in connection with said event(s). I understand that any pictures of me participating in said event may be used for publicity without compensation. I have read and fully understand all terms explained above.

SIGNATURE:
by reentering your name here you indicate that you authorize this form.