Centennial Sportsplex

Private Skating Instruction Request Form

Contact Information
First Name*:
Last Name*:
Address*:
City*:
State*:
Postal Code*:
County:
Home Phone*:
Work Phone:
Fax Phone:
Cell Phone:
Pager Number:
Email Address*:
  *required fields
Skater Information
First Name:
Last Name:
Date of Birth:
Age:
Gender:
Address:
City:
State:
Postal Code:
County:
Home Phone:
Work Phone:
Fax Phone:
Cell Phone:
Pager Number:
Email Address:
Skating Level:
Instruction/Party/Group Information
Type :
Introductory?
Planning to Take Next Group Class Series?
Hockey?
Purpose:
Day of Lesson(s)/Party/Group:
Date:
During This Public Session:
During This Practice Session:
Time:
Length (group instruction is 30 minutes or longer):
Number of Skaters:
Age/Age Range:
Notes:
Print this page for your records before submitting