Private Lesson – Disciplines - Roller Skate Victoria Dance Academy

“Discipline is the bridge between goals and accomplishment.“

– Jim Rohn

This form will lead you into the wonderful world of skating discipline instruction! Please fill it out to the best of your ability so that we can match you with the best instructor to meet your unique goals! Once we receive your form we will be in touch shortly to discuss the first date and time of your private lesson.

Name *

First

Last

Email *

Confirm Email

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Emergency Contact Info

Emergency Contact Name *

First

Last

Emergency Contact Phone Number *

Student Info

Student's Name

First

Last

Is the student under the age of 18? *

What are the student's preferred pronoun(s)?

Are rental skates required?

Rentals are provided free of charge for paid lessons.

If yes, what size. Please specify Men's Women's or Kids sizing.

Lesson Details

To help us pair you with an instructor please provide the following information:

Preferred day(s) of week for lesson(s): *

Preferred time of day for lesson(s): *

Pick a desired 2 hour time block for your lesson. You can choose more than one time block. We will make every effort to schedule your lesson in your chosen time block(s), based on instructor availability.

Indicate your preferred geographical location(s) for your lesson, or choose no preference. *

How long would you like the lesson to be? (30 minutes minimum) *

Please choose the roller skating level/experience that best describes the student's current skill level.

Indicate your desired area of discipline you'd like your lesson to focus on

What other roller skating skills do you want to work on with your instructor?

Any additional information you feel your instructor should know prior to your lesson?

Would you like to set up a recurring lesson?

Name

Thank you from the Roller Skate Victoria Team.