AZ Dance Medicine Specialists - Service Request
Interested in a workshop or seminar for your students or staff? Simply complete our request form and let us know what you're looking for and we will be in touch to schedule a call or video session to discuss details. Interested in hosting our DanceWell Certification Workshop? Go to https://goo.gl/forms/VD7efc2LEkPNxRcB2 to submit a request.

Either way, see you soon!

CONTACT INFO
Your Name *
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Studio Name *
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Studio Address *
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Owner/Director *
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Email *
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Phone *
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REQUESTED SERVICES
What services would you like from AZDM? *
Required
DATES AND TERMS
Select your preferred dates of service based on location. All dates will be confirmed on a first come first serve basis upon receipt of $300 deposit. Your deposit will reserve your chosen day, cover travel, supplies, and admin fees. Class session fees are due on day of service. AZDM accepts cashier's checks, money order, cash, and all major credit cards. We will do everything we can to make sure everyone gets what they requested : ) You will receive an invoice for the deposit amount upon submission of this form.
Dates Requested
Your answer
FEES
Deposit: $300
One session $295
Two sessions: $495
Three sessions: $695
Individual assessments: $155
I have read the dates, terms and fees and understand that deposit is required to confirm services. *
SIGNATURE
Full name
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Date
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