Programs
Dynasty Youth
Gallery
Calendar
Contact
- Rent The Ballroom

Programs
Dynasty Youth
Gallery
Calendar
Contact
- Rent The Ballroom

727.258.7005

Contact

General Questions

First Lesson Form

General Interest/Questions

Full Name*

Please type your full name.

E-mail*

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Phone*

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Message/Question

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First Lesson Form

If you have scheduled your first lesson,
please complete the following form.

Primary Contact Name*

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Primary Contact Email*

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Primary Contact Phone*

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What is date and time of your first lesson?*

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Gentleman's Info

Gentleman's Name

Please type your full name.

Gentleman's Home Phone

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Gentleman's Work phone

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Gentleman's Mobile Phone

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Gentleman's Email

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Gentleman's Birthday (mm/dd)

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I am

Under 21
21 Years or Over Invalid Input

Lady's Info

Lady's Name

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Lady's Home Phone

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Lady's Work Phone

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Lady's Mobile Phone

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Lady's Email

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Lady's Birthday (mm/dd)

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I am

Under 21
21 Years or Over Invalid Input

Address

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City

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State

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Zip

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Anniversary (mm/dd)

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Preferred method for confirmation of lesson

Phone
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May we send e-mails of upcoming events?

Yes
No Invalid Input

How did you hear about us?

I won a lesson at an event
In the yellow pages
I found you online
I received a postcard

I saw your sign
A friend referred me
I saw you newspaper ad

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I was referred by:

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Have you ever had lessons before?

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If yes, where and for how long?

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Are you preparing for a particular event?

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Date of event

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Additional Comments

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What are your area(s) of interest?

Smooth
Standard
Rhythm
Latin
Tango
Salsa

Swing/Jive
Merengue
Cha Cha
Waltz
Samba

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Types of activities in which you would like to be involved?

Social Dance Lessons
Weekly Social Parties
Competitions
Dinner Dances
Weekend Getaways

Weekly Social Parties
Vacations w/ Dance Shows
Local Events
Dance Shows

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Where do you envision yourself enjoying Ballroom Dancing?

Night Clubs
Competitions
Live Music Venues
Cocktail Lounges

Weddings
Formal Events
Restaurants
Other

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What interests you most about taking dance lessons?

Fun/Excitement
Stress Relief
Social Interaction
Exercise
New Interest
Creative Outlet

Personal Development
Improvement in Health
Enhanced Confidence
Glamour
Shared Hobby
Other

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I understand that dance can result in injuries, including but not limited to falls, bruises, or broken bones. I agree not to sue, file lawsuit, or attempt to hold Paramount Ballroom liable for any injuries that may be sustained on the Introductory Lesson, and that I shall be liable for all legal costs incurred by Paramount Ballroom.*

Yes

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