Elizabeth Swimming Lessons at The Gateway Family YMCA

Elizabeth Residents Youth (Ages 4-14) Swimming Lessons

Thank you for your interest in this program. Classes will be held at either our Union or Rahway locations. Please fill out the interest form below. Please note that submitting this interest form does not guarantee placement in the program. Slots are limited and this program is on first come first served basis, you will be contacted shortly if selected.

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* 1. These classes are only available for youth ages 4-14 who are Elizabeth Residents. Do you certify your child meets this criteria?

Yes

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* 2. Please select your child's age range?

4-5 years old

6-14 years old

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* 3. Please select your preferred location (Please note that preferred location is not a guarantee)

Rahway - 1564 Irving Street, Rahway, NJ 07065

Union - 201 Tucker Avenue, Union, NJ 07083

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* 4. Please select the choice which best describes your child's swimming ability:

Starters - No experience and uncomfortable in the water

Basics - Comfortable in the water and is able to submerge head under the water

Strokes - Is able to make forward progression in the water

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* 5. Please provide the participant's information:

Full Name *

Date of Birth

Address *

City/Town *

ZIP/Postal Code *

Parent/Guardian Name

Email Address *

Phone Number *

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* 6. Race/Ethnicity

African-American

Asian

Caucasian

Hispanic

Other

Prefer not to answer

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* 7. Gender

Male

Female

Prefer Not to Answer

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* 8. Number of Individuals in Household

10+

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* 9. Household Income

Under $10,000

$10,001-$20,000

$20,001-$30,000

$30,001-$40,000

$40,001-$50,000

$50,001-$60,000

$60,001-$70,000

$70,001-$80,000

$80,001-$100,000

$100,001+

I prefer not to answer and will go to the YMCA to complete a financial assistance form instead

Elizabeth Swimming Lessons at The Gateway Family YMCA

Elizabeth Residents Youth (Ages 4-14) Swimming Lessons

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* 1. These classes are only available for youth ages 4-14 who are Elizabeth Residents. Do you certify your child meets this criteria?

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* 2. Please select your child's age range?

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* 3. Please select your preferred location (Please note that preferred location is not a guarantee)

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* 4. Please select the choice which best describes your child's swimming ability:

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* 5. Please provide the participant's information:

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* 6. Race/Ethnicity

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* 7. Gender

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* 8. Number of Individuals in Household

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* 9. Household Income

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* 10. I agree to all terms above, and agree to complete a financial assistance form with documentation of income.

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* 11. Digital Signature of Parent/Guardian

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* 12. Date of Digital Signature