Student's Name*

Age

Parent/Guardian Name


Parent/Guardian Name

Street Address*

City*


State*

Home Phone*


Cell

Email*


Please describe the students water experience and skills

Please tell us about any special needs we may need to be aware of
(health concerns, allergies, fear of water, etc.)

How did you hear about us?

Please include times available or not available*

Please select the program you are interested in*
10-day private swim lesson (ten 30 minute lessons) — $325
10-day semi-private lessons (two students in ten 30 minute lessons) — $400