This is a private lesson REQUEST. Your information will be captured and we will do our best to match you with an instructor as soon as possible. Upon completion of this form, an instructor will be in touch with you as lesson times become available. In the event we get more requests than we can handle, you will be added to a waiting list. All fees must be paid in full before lessons begin.

Submissions will be reviewed once a week. Please do not email or call, we will contact you. Thank you for your cooperation and interest in our aquatics program.

PERSONAL/CONTACT INFORMATION

Swimmers First Name *

Swimmers Last Name *

Swimmers DOB *

Phone Number *

Email Address *

Reason for requesting Private Lessons *

Please list the other reason *

LESSON PREFERENCE

Which type of Lesson are you interested in? *

Private (Individual)

Semi-Private (up to 3, the YMCA will NOT fill the other spots for you)

How many Private Lessons are you interested in? *

4 Lessons, 1x/wk (YMCA at ACRC Member = $120, Community Member = $135)

8 Lessons, 2x/wk (YMCA at ACRC Member = $220, Community Member = $240)

How many Semi-Private lessons are you interested in? Prices are per person, up to 3 individuals. You are responsible for finding the other individuals to attend the Semi-Private Lessons) *

4 Lessons, 1x/wk (YMCA at ACRC Member = $80, Community Member = $95)

8 Lessons, 2x/wk (YMCA at ACRC Member = $140, Community Member = $165)

List the names of up to 2 other individuals that plan to do Semi-Private lessons with you: *

Preferred day of the week (select all that apply) *

Preferred time of day *

Preferred Instructor

TELL US ABOUT YOUR SKILLS

Are you comfortable in chest deep water? *

No

Yes

Are you able to put your face in the water? *

No

Yes

Can you comfortably swim the following strokes? (select all that apply) *

Can you swim for 25 yards in any of the following? (select all that apply) *

Do you have experience in any of the following? (select all that apply) *

Any additional information you'd like to share?