YMCA of Greater Charlotte Private Swim Lessons

Center *

Participant First Name *

Participant Last Name *

Participant Gender *

Participant Birthday

Participant Age *

Street Address *

City *

State *

Zip *

Email *

Phone Number *

Referred By *

Referred By - Other

Instructor Preference *

Specific Instructor?

Any conditions that the instructor should be aware of?

Please list illnesses, allergies, diverse abilities or other.

Type Of Request *

All Semi Private and Mini Group lessons must find their partner participants (Ex.: sibling, friend, etc.)

Private Lesson (1 Instructor / 1 Student)

Semi-Private (1 Instructor / 2 - 10 Students)

Mini Group (1:3 Instructor: Student) - (at select branches)

Semi Private Participant

Please include first and last name, phone, and e-mail.

Self Assessment *

Non-swimmer (Uncomfortable in water)

Non-swimmer (Comfortable in water)

Beginner (Can swim 10-15 feet and can float on stomach with face in water.)

Intermediate (Comfortable in water and can swim one pool length)

Advanced (Very comfortable in water and can swim 50 yards-two pool lengths)

Purpose of private swim lesson *

Goals - Other

Do you have any health conditions or important information we need to better serve your needs and find you the right program? *

Yes

Please explain.

Any additional information?