Event Type:
---Private Lesson (1 Child)Semi-Private Lesson (2-4 Kids)Birthday PartySpecial EventSchool EventSpecial Needs

Parents Name, First and Last (required)

Your Email (required)

Best Phone Number:

Day of the Week:

Time:

Child's Name:

Child's Age:

Mailing Address:

Payment Type:
---CheckCashCredit Card

Age Range of Participants:

Coach Preference:
---Coach DerekCoach MikeCoach MichelleOther

Sport(s):

Location:

Please describe your event below:

By hitting the submit button you agree to the follow Coach Derek's policy.

I, the undersigned participant, parent, or guardian, do hereby agree to participate and/or allow the individual(s) named herein to participate in the aforementioned activity(ies) and further agree to indemnify and hold harmless Coach Derek, Inc., its agents and employees from harm, accidents, personal injury or property damage which may be suffered by the aforementioned individual(s) arising out of, or in any way connected with the participation of the activity.