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
Format: (000) 000-0000.
Student #2 Name
First Name
Middle Name
Last Name
E-mail
example@example.com
Mobile Number
Format: (000) 000-0000.
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 (credit card)
Zelle/PayPal:
imagedanceco@gmail.com
Venmo: @dancin4life
Private Lesson Schedule and Availability
I agree to pay the required fee (or have purchased gift certificate) for the scheduled class and will notate my name and time slot on the payment note.
Signed
Submit
Should be Empty: