Private Swim Lessons Application
Student Name *
Address *

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Date of Birth *

MM		/
DD		/
YYYY
Phone Number *

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Swim Lessons Level
 Parent-Tot 
 Preschool 1 
 Preschool 2 
 Preschool 3 
 Land Lubbers (Lvl1) 
 Deckhands (Lvl 2a) 
 Sea Dogs (Lvl 2b) 
 Swabbies (Lvl 3) 
 First Mates (Lvl 4) 
 Capn's (Lvls 5 & 6) 
 Adult Beginnner 
 Adult Stroke Improvement 
Please indicate what level of instruction you are interested in. If you do not know which level is the best option, please leave this section blank.
Guardian/Main Contact

First
Last
If Student is under 18
Relationship to Student
Email
Number of lessons you would like to have *
Do you have a preference for day(s) of the week?
Do you have a prefrence for time(s) of day

HH		:
MM
AM/PM
Do you have a prefrence for time(s) of day

HH		:
MM
AM/PM
Additional Comments
I understand that the cost of Private Lessons is $18 per half hour session,or $30 for 2 students, and that payment is required prior to the lesson taking place. I further understand that I may choose to purchase multiple sessions in advance, and that any failure to appear on *
 Agree 
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