Private Lesson Registration
(One form per child)
Private Lessons are available.
Child rate is $30. Multiple individual children is $20 per child. Adult rate is $40
Practice location and frequency will be determined with instructor.
Participant Information
Are you registering a child or adult for private lessons?
Child
Adult
How many children will be taking lessons?
1
2
3
4
Athlete's Name
*
First Name
Last Name
Athlete's Age
*
Point of Contact
*
First Name
Last Name
Cell Phone Number
*
-
Area Code
Phone Number
Email
*
Confirmation Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Pick-Up Authorization
Please list the full names of ALL persons authorized to pick up your child from RodneyStreet Programming.
Photo identification will be required from ALL persons.
In the event of a custody agreement, which prevents a parent or guardian from picking up your child, we must be provided with a copy
of legal documentation which states such information/rulings.
Please keep this list up to date and notify us immediately if you would like to make changes.
Please notify a staff member in advance, if possible, when someone other than the parent/guardian will be picking up your child.
Please list the individuals that are authorized to pick up your child
*
My child is authorized to walk home
My child is authorized to take public transportation
Back
Next
Save
Emergency Contacts
Please list all emergency contacts
*
*
In the event that I cannot be reached in an emergency, I hereby give my permission to RodneyStreet staff to follow proper Emergency Medical Procedures.
Parent Initials
*
Parental Consent
Please select consent given below and sign.
*
I give permission to have my child, named above, participate in all RodneyStreet programs/activities – this includes transporting child to/from activities, if necessary.
I grant RodneyStreet unrestricted permission to use photographs and/or video and/or voice recordings taken of my child for use in RodneyStreet publications, including web sites or other electronic forms of media. I authorize RodneyStreet, its assigns, and transferees to copyright, use, and publish the same in print and/or electronically. I agree that RodneyStreet may use such photographs of my child, with or without my child’s name, and for any lawful purpose, including, but not limited to, publicity and Web content.
I hereby release Rodney Street, its staff, contractors, and volunteers from any responsibility as a result of any injury to the child named above due to participation in Rodney Street activities.
Signature
Date
-
Month
-
Day
Year
Date
Back
Next
Save
Communications Consent
I understand that as part of the registration process, either one or both parent/guardians listed in this application will be automatically enrolled to receive RodneyStreet communications. This includes the Remind App (a text based service) that will be used by staff for program communications and emails that will include the RodneyStreet monthly newsletter and general organization informational emails. I agree to be enrolled unless I Opt-out below.
I do not wish to be enrolled in the Remind App
I do not wish to receive the RodneyStreet monthly newsletter
My Products
prev
next
( X )
Child Private Lesson
$30.00
$
30.00
Individual private lesson.
Quantity
1
2
3
4
5
6
7
8
9
10
Adult Private Lesson
$40.00
$
40.00
Multiple Children Private Lesson
$20.00
$
20.00
Quantity
2
3
4
5
6
7
8
9
10
Total
$0.00
$
0.00
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Save
Submit
Should be Empty: