Name *

First Name

Last Name

Phone *

(###)

###

####

Whats the Occasion? *

Private Dance for him/her

Self Care

Fitness Related

Just because

Video/Performance

Other

Dance Level? *

None at All

Beginners

Intermediate

Advanced

Type of Dance/Fitness Style? *

Twerk (gymshoes)

Sensual Movement (Tease, no shoes)

Hip Hop

Lap Dance (Nobody in Chair)

Lap Dance (Person in the chair)

Heels

Flexibility (Stretching)

Additional People? (You are allowed to add on up to 3 ppl max. for a session at $50 p/person ) *

If you would like to add on additional persons to a 1-on-1 session, you can add up to 3 persons (4 in total including yourself). It will be $50.00 each additional person. Again this form is NOT for private parties ( strictly choreography only)!

1 person (Just Me)

2 people (Me +1)

3 people (Me +2)

4 people (Me +3)

Have you experienced Kookie's Dance Den before? *

Yes

No

Location? Please provide the location for your session ( Full Address). Location must have mirrors and wood flooring. *

Sessions will not be booked without a location.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Disclaimer *

This form serves as your legally binding request. If anything changes on your behalf, you will need to resubmit your form in order to have the final request on file.(You are more than welcome to make changes after it is submitted, however those changes may result in a cancellation on your behalf if we can accommodate it by it being last minute or by it being requested in an improper way.) This form is simply your request which upon submission will be reviewed in hopes to confirm a date/time for your session. Requests are not confirmed without a payment receipt + email confirmation with date/time confirmed. Do you agree that the above information is your request ?

Yes

No