Private Swim Lesson Interest Form

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

Please check all of the boxes that the swimmer is capable of:

Swimmer can put face in the waterSwimmer can float on stomach or backSwimmer can swim front crawlSwimmer can swim back crawlSwimmer can swim elementary back strokeSwimmer can swim breaststrokeSwimmer can swim side strokeIf you are unsure, please leave unchecked.

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

Do you have a preferred pool?

What are the goals for the lesson(s)?

Preferred Swim Times

When would you like to start?

Additional Comments / Questions

Please check all of the boxes that the swimmer is capable of:

Preferred Swim Days