Private Swim Lesson Application

First Name

Last Name

Address

City

State

Zip

Birthdate

Date

First & Last Name(s)

Cell Phone Number

Home Phone Number

Email Address

	Yes	No
Can put face in Water	Can put face in Water Yes	Can put face in Water No
Can front & back float	Can front & back float Yes	Can front & back float No
Can swim freestyle	Can swim freestyle Yes	Can swim freestyle No
Can swim all 4 strokes (freestyle, backstroke, breaststroke, butterfly)	Can swim all 4 strokes (freestyle, backstroke, breaststroke, butterfly) Yes	Can swim all 4 strokes (freestyle, backstroke, breaststroke, butterfly) No

Morning (8am–Noon)

Afternoon (Noon–3pm)

Evening (3–7pm)

Mondays

Tuesdays

Wednesdays

Thursdays

Saturdays

Date