Your Information

Parent's Namerequired

Swimmer's Namerequired

Swimmer's Date of Birthrequired

Emailrequired

Phonerequired

Do you have an Athletic Center membership?*

Yes No

Address

Street Address 1required

Street Address 2

Cityrequired

Staterequired

Zip Coderequired

Lesson Details

How long do you want the lesson to be?*

30 minutes ($60 per session) 45 minutes ($90 per session) 60 minutes ($120 per session)

Swimmer Details

Please check all that describe the swimmer:

Afraid of water Able to put face in water and hold breath Comfortable in deep water Not able to swim more than 10 yards Able to swim several laps Swimmer is an adult

Swimming Goalsrequired

Note: It will take 1-2 weeks for lessons to start after form is submitted.