Adult Single

Square Dance Lessons Registration
for Adult Single

Please register me for the next session of
Rockin’ Squares Dance Lessons
Please create my name badge using my first name below.

See Lessons Page for pricing and information

Choose One *

Zelle (use QR Code at bottom of page after submitting application) Check

Choose One (Mainstream includes SSD calls): *

Mainstream (Basic) Mainstream (Part 2) Plus

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Alt. Phone Number *

Birthday *

Email *

I hereby give permission for my phone, birthdate, (not year), and e-mail to be shared with members of the club. *

YES NO

I also understand photos and videos may be taken during classes and at dances which may be used in the future for marketing purposes and give my permission for these photos and video to be shared within the square dance community. *

YES NO

Dancer's Signature *

(By typing name here acknowledges electronic signature)

Date Signed: *

EMERGENCY CONTACT INFO

Emergency Contact Name *

First

Last

Relationship *

Emergency Contact Phone *

Emergency Contact Email *

Submit Registration Form

Once you submit the application, please use the QR Code below to make your payment