Private/semi-Private Swim Lesson Request Form Page 2

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Sage YMCA
Private/Semi-Private Swim Lesson Request Form
Parent’s Name ________________________
Phone number____________
Participant’s Name _____________________
Age (Must be at least 3)_____
Participant’s Name _____________________
Age (Must be at least 3)_____
Participant’s Name _____________________
Age (Must be at least 3) _____
Interested in:
□ Private lessons
□ Semi-private lessons
Are the participants members? □ Yes
□ No
Instructor Request (if available):_________________
Anticipated Start Date: _______
Day/Time Availability*
Monday Times: ____________________________________________________________
Tuesday Times: ____________________________________________________________
Wednesday Times: __________________________________________________________
Thursday Times: ____________________________________________________________
Friday Times: ______________________________________________________________
Saturday/Sunday Times: _____________________________________________________
*Please note that private lessons are not scheduled during regular group class hours.
Level of participant/s:
□
□
Never been in/does not like water
Can swim, needs stroke refinement
□
□
Likes the water but has no formal instruction
Other: ____________
□
Can float unassisted, has some movement
I, ____________________, have read and understand the policies as they relate to the Sage YMCA
and private/semi-private lessons concerning procedures, payments, scheduling and cancellations.
Acknowledged and agreed: _______________________________________ Date: _________
Office Use Only
Scheduled Day/Time: ______________
Amount Due: $ _____________
Beginning Date: ______________
Authorized by*: _____________
*Note to Member Services:
Please do not accept payment without authorization from the Aquatics Coordinator.
Date Paid: _________
Staff Initials: _________

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