Private/Semi-Private Class Request Form

First name

Last name

Company name

For Reps. requesting information for a client, please feel free to share pertinrnt info with me privately.

Name Of Contact for Talent

Manager, Agent

Email

Phone

Age Range

I understand that anyone under 18yrs must have Parental Consent. Scheduling for minors is only to be done via Parent, Managemnt or Agent.

Tell Me About Your Artistic Interest

Class Type

What are your long term movement/dance goals?

Tell me what you want to get out of your sessions.

Dance Training, Artistic Experience, Athletic Experience

Please list your training and/or experince level.

Athletes, What Sport Do You Play?

Please list any injuries and/or concerns..

List all injuries and/or areas of concern

Have you had surgery for any injuries in the past 24 months?

YES

NO

If You checked "YES" above please provide details.

*Only answer if you checked "YES" above.

If you have had surgery in the past 6 months: Have you been cleared by your Physician to begin gentle exercise?

YES

NO

*Please always seek the guidance of your Physician before beginning an exercise or training after injury and/or surgical procedures.

Are you currently experiencing discomfort due to injures that prevent you from participating in dance classes, rehearsals, or athletic practice?

YES

NO

If yes, list current issues of concern.