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Sam & Denise Miller

Please submit a separate form for each Student under 18. Partners are not required.

Student Name(s):
Address:
City:
State:
Zip:
E-mail:
Daytime Phone:
Evening Phone:
Guardian Name & Contact:	(Required for Students under 18)

			# Dancers		Amount
Friday, 7:00-8:30pm		Better than a Movie - $15/person, $27/couple		$
Saturday, 3:00-4:00 pm		Cha Cha : Mechanics 1 - $12/person		$
Saturday, 4:15-5:15 pm		3-Count Hustle : Mechanics 1 - $12/person		$
Sunday, 3:00-4:00 pm		West Coast Swing: Mechanics 1 - $12/person		$
Sunday, 4:15-5:15 pm		Country Two-Step: Mechanics 1 - $12/person		$
All Four 1-Hour Workshops - $40				$


	TOTAL			$

	I am interested in taking semi-private lessons in the following style(s):
	I am interested in taking private lessons.

	Registration Fees will be due at the door. Thank you for registering!

540-382-8782 - info@sapphiredance.com