Couples Ballroom Registration

Full Name:*

Email:*

Name of other participant (spouse, partner):*

Date of Birth:*

Phone:*

Address:*

City/State/Zip:*

How did you hear about this class?

Current Client of ECS:*

Yes

Couples Ballroom is offered for 4 weeks. You may register for one or more classes. Let us know which dates you plan on attending :*

February 4

February 11

February 18

February 25

Emergency Contact Information:

Contact Name:*

Relationship:*

Contact Phone Number:*

Questions, concerns, or to register over the phone, call our office 610-282-5735 or email [email protected]

Because this group is therapeutic in nature, each person registering for a group will be expected to sign into our client portal, Therapy Appointment. In Therapy Appointment you will be able to pay for the group, see the class schedule and submit insurance information, if necessary. More information about how to sign in will be sent upon completion of this form.

For groups or events requiring pre-registration, no-shows or cancellations less than 24 hours will be charged the cost of the group. Thank you!