2. Today's Date*
   Today's Date
5. Person filling out form:
6. First Name
7. Last Name
9. Participant:
10. First Name
11. Last Name
13. Phone:*
    Please give us the best phone number to reach you at.
14. Email:
16. Age
17. Swimming Level
    Last level of swim lessons taken (if known)
19. Swimming Ability
21. Reason for request
23. Dates/Times Availability and Instructor Requests:
    We try to honor all requests possible. Actual lesson times are negotiated between the instructor and participant.
Leave This Blank:


25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit Submit and Print

* indicates a required field