Class Request Form

Instructions: Please read before you fill out – and fill out form completely.

Payment Type:


Coach Preference:

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.

Register online and MAIL PAYMENT TO:
Derek Locklear PO Box 1260 Manhattan Beach, CA 90267
(Checks payable to Coach Derek, Inc.)