Private Swim Lesson Interest Form | Prairie Athletic Club

Swimmer's First Name *

Swimmer's Last Name *

Responsible Adult

Adult First Name *

Adult Last Name *

Adult Phone *

Adult Email Address *

DOB *

Month *

Day *

Year *

Age of Swimmer *

Contact Information

Swimmer Phone Number *

Swimmer Email Address *

Are you interested in Private or Semiprivate lessons? *For Semiprivate lessons, swimmer will need to supply partner(s) that can attend at the same time and have a similar ability level.

Additional SwimmersPlease list only the names of the additional swimmers in the semi-private group

Additional Swimmer First and Last Name

Preferred Swim Times

Does the Swimmer have any health history that we should know about?

Will a third party be purchasing lessons?YesNo

What are the goals for the lesson(s)?

Additional Comments / Questions

Third Party Information

First Name

Last Name

Caseworker Email *