The Works Family Health and Fitness Center Private Swim Lesson Request

Participant First Name

Participant Last Name

Street Address

City

State

Zip Code

Phone

Email

Participant Date of Birth

Participant Age

Parent/Guardian Name (if applicable)

Members at The Works?

Yes

No

Participant Swimming Ability
(select all that apply)

Wears floaties

Comfortable with face wet/blowing bubbles

Comfortable going underwater

Comfortable in water over their head

Swimming on front with assistance

Swimming on back with assistance

Swimming on front/back independently

Participant Swim Lesson Background
(select all that apply)

First time EVER taking Swimming Lessons

First time taking PRIVATE Swim Lessons

Has taken private swim lessons before.

Has taken group swim lessons before.

If the participant has taken private swim lessons before, where were they taken?

If the participant has taken group swim lessons before, what was the level and location?

Below, please days and times you are available for swim lessons

Disclaimer: this is no guarantee for placement to get lessons

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Are you interested in semi-private lessons?*

*There must be another participant that will enroll � The Works Aquatics staff do not match participants.

Yes

No

If yes, please fill out the information for the other student below

Student Name

Date Of Birth

Phone Number

Other Helpful Information For Instructor

Print Name

Signature

Date