Personal C/C

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Contact Information

Anestea Services 

Registration Form

 


 

Please Fill out the Following form.





Add more: Numbers/ Email
Address





Date of Birth:







(
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Enter Another Phone # or Email.

Anestea Services



Private



Member

Each member of your Group needs to Fill out an Information/ Registration from.

Each Member of your Group needs to Fill in the The Same Group name.


Non-Member

Each member of your Group needs to Fill out an Information/ Registration from.

Each Member of your Group needs to Fill in the The Same Group name.


Day and Time:


Ä Online Calendar

Follow the above link for available dates/ times

 Ä Prices for private sessions

Follow the above link for available prices





Group


Select Another Day & Time.

Type:


Enter More Experience
Type:


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Type:



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Type:



Enter More Experience
Waiver

Release:

I hereby consent to participate in activities offered by Anestea Services and or Angela L. Carmichael Smith. 

 

It is hereby agreed that I and/or my children waive and release all right and claims for damages that I and/or my children may have at any time against Anestea Services or Angela L. Carmichael Smigh, and/or any associated representatives whether paid or volunteer; for any injury of damages in connection with any and all programs or other activities related to the programs offered. 

 

The risks involved in respect to such a program are fully understood.

Permission for Medical Treatment:

I confirm that the previously named person is in good health unless indicated below.  I hereby authorize simple first aid.


Type

Enter another Concern
Concerns/ INFO:






By typing you First and Last name here you acknowledge that all the information given in correct to the best of your knowledge and you agree to the waver conditions as indicated.