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2. DATE RECEIVED
   DATE RECEIVED

   DATE RECEIVED
4. Swimmer's Name
5. Swimmer's Birthday
7. Phone Number
8. Email Address
10. Which Lifesaving swimming level has the swimmer last completed? (If applicable)
12. Please Click One!
14. Parented (3-6 Months)

    1. Parent and Tot 1
    2. Parent and Tot 2
    3. Parent and Tot 3
    4. Unknown
15. Preschool (3-5 Years)

    1. Preschool 1
    2. Preschool 2
    3. Preschool 3
    4. Unknown
16. Swimmer (6+)

    1. 1
    2. 2
    3. 3
    4. 4
    5. 5
    6. 6
    7. Unknown
17. Another Category

    1. Rookie
    2. Ranger
    3. Star
    4. Unknown
19. Is there anything in particular that you, or your swimmer, would like to work/focus on?
21. Additional Comments:
23. Please Note: If an instructor is available to take this lesson, they will contact you and set up dates and times. Please remember that this is an application form and does not guarantee you or your swimmer a private lesson. We will do our best to accommodate you!
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

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