Private Swim Lesson Request Form

 

General Information

Participant's Name
Participant's Age
Participant's Swimming Experience
                                           
Participant's Red Cross Swim Level (if known)
E-Mail Address
Preferred Phone Number 
Membership Status
                                    
 
 
Rice ID # (if applicable)  

Emergency Contact or Parent/Guardian Information

Name
Phone Number 
Relationship to Participant    


Lesson Availability

When are you available to meet with an instructor?
Please select all that apply
Monday
      
Tuesday
      
Wednesday
      
Thursday
      
Friday
      
Saturday
               
Sunday
      
   
How many lessons are you requesting?
                   
How many lessons would you like each week?
  

Instructor Preferences

Instructor
                              
If you know of a specific
instructor you would like
to request, please list here:
 

What do you (or your child) want to accomplish by taking these lessons?

                    


 Do you (or your child) have any medical conditions or special needs?