Adult(s) and Youth(s)

Square Dance Lessons Registration
for Adult(s) and Youth(s)

Please register us for the next session of
Rockin’ Squares Dance Lessons
Please create our name badges using our first names 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 Basic includes SSD calls): *

Mainstream Basic Mainstream Part 2 Plus Level

* Indicates required field

Adult 1 Name *

First

Last

Birthday of 1st Adult *

Adult 2 Name *

First

Last

Birthday of 2nd Adult *

Youth 1 Name *

First

Last

Birthday of 1st Youth *

Youth 2 Name *

First

Last

Birthday of 2nd Youth *

Names and Birthdays of Additional Youths *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Alt. Phone Number *

Email 1 *

Email 2 *

We hereby give permission for our phone numbers, birthdates (not year), and e-mail addresses 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 our permission for these photos and video to be shared within the square dance community. *

YES NO

Adult Dancer 1's Signature *

Adult Dancer 2's Signature *

(By typing names here acknowledges electronic signature)

Date Signed: *

EMERGENCY CONTACT INFO

Emergency Contact Name *

First

Last

Relationship *

Emergency Contact Phone *

Emergency Contact Email *

Submit Lesson Registration

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

Please fill out a Youth Permissions form for each youth