Private Swim Lesson Request Form

Please complete one per swimmer.

Student's Name(Required)
Gender(Required)
MM slash DD slash YYYY
Parent/Guardian's Name (if applicable)
Mailing Address(Required)

Emergency Contact

Emergency Contact's Name(Required)

Student Information

Has the student taken lessons before?(Required)
Please check all of the student's current skills:(Required)

Days & Times Available:

Please check all that work for your schedule
Monday
Tuesday
Wednesday
Thursday
Saturday
Sunday
Are there any details you can provide regarding how many people need lessons, if there is a specific instructor you would like to learn with, or what you would like to accomplish during swim lessons?