Private Swim Lesson Request Form

Child’s Name:(Required)

Parent/Guardian Name:(Required)

Date of birth:

Age:(Required)

Member / Non-Member(Required)

Member

Non-Member

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number:(Required)

Email Address:(Required)

Please list all times you that you are available for lessons to help match you with an instructor:

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Sunday:

GOALS FOR MY SWIMMER:

Stay Curious