Course Registration Form

Private Lesson Client Registration Form

Fill out the form carefully for registration
Student #1 Name*

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Work Number
Student #2 Name

First NameMiddle NameLast Name
E-mail
example@example.com
Mobile Number
Styles of dances
Other style of dance preferred
I agree that there are special rates on an hourly rate for private lessons. It is at the discretion of Image Dance to offer a package rate.
Signed
Should be Empty:

Private Lesson Client Registration Form