Private Swim Lesson Request Form

2. Today's Date*
   Today's Date

5. Person filling out form:

6. First Name

7. Last Name

9. Participant:

10. First Name

11. Last Name

13. Phone:*

    Please give us the best phone number to reach you at.

14. Email:

16. Age

17. Swimming Level

    Last level of swim lessons taken (if known)

19. Swimming Ability

21. Reason for request

23. Dates/Times Availability and Instructor Requests:

    We try to honor all requests possible. Actual lesson times are negotiated between the instructor and participant.

Leave This Blank:


25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit Submit and Print

* indicates a required field