Private Lesson Client Registration Form
Fill out the form carefully for registration
Student #1 Name
*
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
example@example.com
Phone Number
Student #2 Name
First Name
Middle Name
Last Name
E-mail
example@example.com
Mobile Number
Styles of dances
Please Select
Salsa
Merengue
Country/Western
Tejano
Cumbia (specify style)
Latin Ballroom
Foxtrot
Bachata
Huapango
Rumba
Other (specify below)
Other style of dance preferred
*
Secure Your Lessons Here
PayPal:
imagedanceco@gmail.com
Venmo: @IDCA1
Private Lesson Schedule and Availability
I agree to pay $25 for the scheduled class and will notate my name and time slot on the payment note.
Signed
Submit
Should be Empty: