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2. DATE RECEIVED
4. Child's Name
5. Parent/Guardian Name
7. Child's Birthday
8. Phone Number
10. Email Address
12. Which Red Cross Swimming level is your child currently in?
14. Parented (3-36 months)

    1. Starfish
    2. Duck
    3. sea Turtle
    4. Non of the above
15. Preschool (3-5 years)

    1. Sea Otter
    2. Salamander
    3. Sun Fish
    4. Crocodile
    5. Whale
    6. Non of the above
16. Swim Kids (6+)

    1. Level 1
    2. Level 2
    3. Level 3
    4. Level 4
    5. Level 5
    6. Level 6
    7. Level 7
    8. Level 8
    9. Level 9
    10. Level 10
    11. Non of the above
18. Is there anything in particular you would like your child to focus/improve on?
20. Are there any medical condition the instructor should be aware of?
22. Additional comments
24. Please Note: If an instructor is available to take this lesson, you will recieve an email to set up dates and times. Please remember that this is an application form, and does not guarantee your child a private lesson, though we will do our best to accommodate you.
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26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit Submit and Print

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