Skate Lesson Program
& enrollment form
To sign up: just print out the form & bring it
to the 1st day of class OR scan & email it to:
Lisa @EmpireRollerRink.com
Roller Skating Enrollment Form - Empire Roller Rink

Todays date:    
___________________________________________________

Date of Class:  
__________________________________________________

(Circle one)
  Level 1  (beginner)                   Level 2                                Level 3

Name:_________________________________________________________

Age:
____________________________DOB:_________________________

Parents
Names:__________________________________________________

Home Address:
__________________________________________________

                      
__________________________________________________

Email:
__________________________________________________________

Home Phone:
__________________________Cell:______________________

Shoe Size: ____________________School
Enrolled:_____________________

Paid:_____________________________________________________________

Payment can be made at the beginning class date. Any questions call
Lisa Trent at (573) 443-7375 or email at
Lisa@empirerollerrink.com.  
Thanks!