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 *

Parent First Name *

Parent Last Name *

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 A LITTLE ABOUT YOUR CHILD

Does your child respond to verbal cues? *

No

Yes

Is your child comfortable without a parent or guardian near? *

No

Yes

Can your child blow bubbles through their mouth and nose under water? *

No

Yes

Can your child go completely underwater unassisted? *

No

Yes

Can your child jump into chest deep water unassisted without a flotation device? *

No

Yes

Can your child float on their back AND their front on their own without the use of a flotation device? *

No

Yes

Can your child swim 10-15 yards unassisted on their front and back? *

No

Yes

Can your child swim the front crawl, back crawl and the breaststroke across the pool unassisted? *

No

Yes

Does your child know all the strokes and can swim 25 yards (1 length of our pool) using the front stroke/backcrawl? *

No

Yes

Does your child have any experience in an of the following? (select all that apply) *

Any additional information you'd like to share?