Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Additional Student Name

For example: if you have a spouse or friend or your child name...

First Name

Last Name

Phone for Additional Student

(###)

###

####

Address for Additional Student

If address same as above - skip to GENERAL QUESTIONS section

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What type of dance would you like to learn?

Please check one or more.

Tango

Foxtrot

Waltz

Quick Step

Viennese Waltz

Argentine Tango

Cha Cha

Rumba

Samba

Jive

Swing

Salsa

Other:

Special Request for such as

Wedding

Anniversary

Birthday

Family celebration

Other:

Date of your event

MM

DD

YYYY