Dance Intake Form

Health for Dance with Estelle Enrollment Form

Welcome to Health for Dance with Estelle! Before we start dancing, please take a moment to tell me a little about yourself and your dance goals! Thank you so much for your time.
Your Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
On a scale of 1 to 10, please rate your passion or curiosity for dance.*
1=lowest, 10=highest
Do you currently have an exercise/movement regimen?*
Please select one of the above options
How often do you exercise or move your body?*
Please select one of the above options
Have you taken dance lessons before? *
If 'Yes', please describe your dance experience in a couple sentences, however great or small...
If you answered 'Nope' to the previous question, you may skip this question.
Have you danced with Estelle before? Please select all that apply.*

Yes, I take ongoing lessons with EstelleYes, I used to and want to dance with Estelle more regularlyYes, but it's been awhileNo, this will by my first time
What type of dance most interests you?*
List one or a few so we know your primary interests.
I consider myself a(an)... (Please select all that apply.)*

An absolute beginner. I have never taken a dance class ever in my life.A beginner with some dance class experience.An intermediate dancer. I have at least 5 years of dance class experience.An intermediate to advanced dancer. I have 5-10+ years of dance experience with some performance experience.An advanced level dancer with a lot of performance experience.A professional dancer. I dance full time and earn income dancing!
What are your dance goals? Please select all that apply.*

I want to learn a specific dance for an upcoming event.I am looking for a fun way to add movement to my exercise regimen.I am passionate about learning to dance but never had the time.I am very shy and want to feel comfortable dancing with others.I want to improve my health through dancing.I am looking for a fun, new activity to spice up my social life.I want to be a part of a community of like-minded people.Other
I am interested in... (Please select all that apply.)*

Private LessonsSmall Group LessonsOther
I prefer to dance via... (Please select all that apply.)*

In-Person LessonsOnline Virtual LessonsOther
What are the biggest obstacles getting in the way of accomplishing your dance goals? Please elaborate.
Do you have any physical or health limitations that we should know about before we begin? Please elaborate.*
It is your responsibility to ensure you are cleared by your qualified healthcare practitioner for movement. Otherwise, feel free to indicate any recent or past injuries. We will work within your capabilities!
How ready are you to start integrating dance into your life NOW?*

I am SO ready! Let's Dance!I really want to but may need more information.
Thank you SO MUCH for taking the time to complete the HFD Enrollment Form. The information that you have provided will remain confidential and will help me in providing you with the most invaluable and extraoradinatry dance experience.

To complete your enrollment process, please submit your $35 (non-refundable) enrollment fee, that will be applied to your first lesson upon review and approval.

If you have any questions, pelase email: admin@healthfordance.com
Disclaimer: Although what we work on may empower your health, we cannot and will not diagnose, treat or mitigate any disease. Any information provided by Health for Dance is not a substitute for professional medical help.
Please verify that you are human*
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Health for Dance Intake FeeNon-Refundable - applied to your first lesson upon review and approval.
$35.00

Total

$0.00

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Health for Dance with Estelle Enrollment Form