Please Note: All request must be confirmed by Lakeshore Roller World!

(By submitting your request, you agree that we may contact you. Contact may include email, phone, fax and/or mail by carrier.)

First Name: Last Name:

Organization Name:

(If Applicable)

E-mail Address: Web Address:

(I.e. someone@anywhere.com)

Business Phone: -- Alt. Phone/Cell: --

Home Number: -- Fax Number: --

What type of event would you like to schedule?

If "Other" selected, please specify event. Estimated Attendance

Please select preferred event dates and times as well as two alternative choices.

Preferred Date and Time

Date

. --

(I.e. Sun. 07 - 27 - 08)

Public Session Time

Private Session Time

From : To :

Time Allowance: Weekdays 2 hours or Weekend 2.5 hours

Alternative One Date and Time

Date

. --

(I.e. Sun. 07 - 27 - 08)

Public Session Time

Private Session Time

From : To :

Time Allowance: Weekdays 2 hours or Weekend 2.5 hours

Alternative Two Date and Time

Date

. --

(I.e. Sun. 07 - 27 - 08)

Public Session Time

Private Session Time

From : To :

Time Allowance: Weekdays 2 hours or Weekend 2.5 hours

If event is a birthday party, please complete the following:

Birthday Person #1's First Name Birthday Person #1's Last Name

How old will Birthday Person #1 Be?

Birthday Person #2's First Name Birthday Person #2's Last Name

How old will Birthday Person #2 Be?

Birthday Person #3's First Name Birthday Person #3's Last Name

How old will Birthday Person #3 Be?

If you have any questions please e-mail us: rollerwo@sbcglobal.net
(269) 429-7700 or (888) 91-SKATE
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