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Private and Semi-Private Swimming Lessons

Please complete the final registration form for YourSwimmingSpace.com Private and Semi-Private Swimming Lessons. Answer all questions as fully and completely as possible. We will use your answers to customize your program.

Swim Lesson Registration and Release Form

Please note that all fields followed by an asterisk must be filled in.

Package*
Package*

Number of packages*
Number of packages*

Student 1: Name *
Student 1: Name *

Age*
Age*

Sex*
Sex*

Student's Swimming Background*
Student's Swimming Background*

If student has taken Red Cross lessons, to what level?

Please describe any special health conditions

Please describe any other special circumstances (ex: fear of water)

Any specific goals for the session?

Student 2: Name (for semi-private or split sessions)

Age

Sex

If student has taken Red Cross lessons, to what level?

Please describe any special health conditions

Please describe any other special circumstances (ex: fear of water)

Any specific goals for the session?

For multiple students: How will lessons be divided?

Access to a pool? (Client usually provides pool)*
Access to a pool? (Client usually provides pool)*

	Yes
	No (Please explain below)

Starting Date*
Starting Date*

Starting Time*
Starting Time*

Lesson Frequency (ex: M-W-F)*
Lesson Frequency (ex: M-W-F)*

First Name*
First Name*

Last Name*
Last Name*

E-mail Address

Street Address*
Street Address*

City*
City*

Zip/Postal Code*
Zip/Postal Code*

Home Phone*
Home Phone*

Alternate phone number *
Alternate phone number *

I prefer to be contacted by

Referral discount: Signing up with a friend? Please list his/her name here

Any coupon codes?

Your Registration is nearly complete. Please read our Policies and Liability Release Form and then check the following boxes.*
Your Registration is nearly complete. Please read our Policies and Liability Release Form and then check the following boxes.*

	I have read and agree to YourSwimmingSpace.com Aquatics Policies.
	I have read and agree to YourSwimmingSpace.com Aquatics Liability Release Form.

Please initial here*
Please initial here*

Would you like to sign-up for our newsletter?

	Yes, please sign me up to receive occasional promotions and discounts as well as swimming tips and advice.
	No, thank you.

Additional Comments or Questions

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Testimonials

Here are some real testimonials from past clients:

Christine writes,"I couldn't have asked for a better swim teacher for my son. My instructor was low-key, always positive and made my son feel comfortable even with his fear of the water. I recommend her highly.”

Sandy writes,“I was extremely pleased with the level of expertise by the instructor. My granddaughter is somewhat timid in the water and doesn't like to try new things. Our instructor was encouraging, knowledgeable and persistent. She got my granddaughter to try things I was amazed at. She is certainly an exceptional swimming instructor, especially for children.”

Shanna writes, “YourSwimmingSpace.com was great! They are very well prepared and professional! Well worth the money!”

For more testimonials, click here...

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Complete Your RegistrationPrivate and Semi-Private Swimming Lessons

Testimonials

Complete Your Registration
Private and Semi-Private Swimming Lessons