Contact Person / Parent *

First Name

Last Name

Cell Phone Number *

(###)

###

####

Home Phone Number

(###)

###

####

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child #1 Name *

First Name

Last Name

Birthday *

MM

DD

YYYY

Had Lessons Previously *

Yes

No

Level of Swimmer's Ability *

Non-swimmer

Beginner Swimmer

Intermediate Swimmer

Baby & Me

Child #2 Name

First Name

Last Name

Birthday

MM

DD

YYYY

Had Lessons Previously

Yes

No

Level of Swimmer's Ability

Non-swimmer

Beginner Swimmer

Intermediate Swimmer

Baby & Me

Check the preferred start month for lessons:

June 28th

July

August

September

Preferred Start Date for Lessons

MM

DD

YYYY

Preferred Days for Lessons (lessons are offered Monday - Thursday)

For the Baby and Me lessons please specify preference of Monday & Wednesday OR Tuesday & Thursday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Check the time that you would like your private lesson to be held

This is for private lessons only.

9:00 - 9:30am

9:30 - 10:00am

10:00 - 10:30am

10:30 - 11:00am

11:00 - 11:30am

4:00 - 4:30pm

4:30 - 5:00pm

5:00 - 5:30pm

5:30 - 6:00pm

6:00 - 6:30pm

6:30-7:00pm

Check the time you would like your Baby & Me lesson to be held

This is for Baby & Me lessons only

10:00 - 10:30am

10:30 - 11:00am

11:00 - 11:30am

4:00 - 4:30pm

4:30 - 5:00pm

5:00 - 5:30pm

5:30 - 6:00pm