Week 1 - Student Readiness & Responsibility Agreement


In the first week of a beginner level class where there are new students, I ask them to fill out a Student Readiness & Responsibility Agreement (SRRA).

I teach about the basic movement vocabulary of the dance - isolation of circles, lines, waves and how these move in the natural lines of the body - and I give a general history of the dance.

I talk about these things so that new and returning students can become aware that they are learning this dance from where they are in their bodies Right Now and to take responsibility for that.

To me, this includes 2 very important things:
1) a student must listen to themselves, stop a movement if there is pain and tell me if something is not feeling right
2) a student must learn to be compassionate with themselves and their bodies as they are leaning a new movement vocabulary

I ask students to fill out the SRRA form (see below) not only for my insurance but also because it gives students and me a chance to check-in on where they are at in their bodies when they start classes.

Here is a copy of the present SRRA form:


A regular program of physical exercise is a fun and healthy activity. The bellydance classes taught by Studio Sephira require exertion. Generally speaking, intensifying your physical activity does not significantly increase your health risk. However, in some cases, a visit to your doctor is recommended before you start a new exercise program or increase your level of physical activity.

Please read carefully the following and check any conditions that may apply to you
___1. You are pregnant or think you might be.
___2. You wear orthotics.
___3. You are not involved in sports or physically strenuous activities.
___4. You have a heart problem and activity must be medically approved.
___5. You have experienced chest pains when exercising.
___6. You have experienced chest pains when not exercising.
___7. You are prescribed medication for blood pressure or heart problems.
___8. You are prescribed medication for a physical injury.
___9. You have problems with your balance because of dizziness.
___10. You have had episodes of fainting.
___11. You have trouble with your bones or joints.
___12. You are recovering from a surgery.
___13. You have other reasons why you should refrain from physical activity.
Please specify reasons: __________________________________________

IF ONE OR MORE OF THESE APPLY TO YOU, you should visit your doctor BEFORE increasing your level of physical exertion. Explain to your doctor the activity you wish to undertake and follow his or her advice.

I, __________________________________ have been informed of the need for a physicians approval for participation in Bellydance classes. I fully understand the strenuous nature of the program and choose not to obtain a physician’s permission.

Considering that my participation in Bellydance classes given through Studio Sephira is entirely voluntary. I recognize that:

a) I am responsible for consulting my doctor.
b) I am responsible for informing the class instructor of any injuries or special instruction I may require.
c) I have the right and responsibility to choose which exercise I will perform.
d) I have the right to abstain from any activity.
e) I have the right to refuse any form of touch that may be used in these courses.

I have carefully read all the articles contained in this consent form, and to my knowledge, do not have any limiting physical condition or disability, which would preclude and exercise program.
I accept the full responsibility for my health and well being in regards to participating in Bellydance classes taught by Studio Sephira. I agree that neither the owner of the Studio (Barbara Aubie), her agents, her relations, nor the facility (directors, owners or employees) in which the classes take place, will be held responsible for damages of any kind.

Signature ________________________________ Date ________________

Guardian ________________________________ Date ________________
(if 18 years or less)

Please Note:
-In case of illness, please provide a doctor’s note to obtain an extension for classes.
There are NO refunds.
-If you are suffering from fever, flu or some other transient illness, it is preferable that you wait till you have recovered before attending a class.
-Please respect people who are scent sensitive and refrain from using heavy perfumes, etc. during your workout.