Diverse Abilities Swim Lesson Request Form

Please complete one per swimmer.

Student's Name(Required)
Gender(Required)
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. Requesting lessons doesn't guarantee immediate lessons.
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?