Semi-Private Swim Lesson Request Form

 

Participant #1

Participant's Name  
Participant's Age  
Participant's Swimming Experience
                            
Participant's Red Cross Swim Level (if known)


Participant #2

Participant's Name  
Participant's Age  
Participant's Swimming Experience
                            
Participant's Red Cross Swim Level (if known)


Participant #3

Participant's Name  
Participant's Age  
Participant's Swimming Experience
                            
Participant's Red Cross Swim Level (if known)


General Information

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 does the group (or your children) want to accomplish by taking these lessons?

                 


Does anyone in the group have any medical conditions or special needs?