Association Private Swim Lesson Request Form

YMCA of the Chippewa Valley

Private Swim Lesson Request Form
Participant Information

Private and Semi-Private Swim Lessons are offered for all levels and 3 years of age and older. Participants work on swimming skills appropriate for their ability and in accordance with their individual goals. Water safety is stressed to all participants. Private lessons are 30 minutes long, please be ready for your scheduled time. Instructors are not obligated to stay longer than the scheduled timeframe. The length of time to complete all of your purchased lessons varies depending on the facility your lessons will be held. Contact the appropriate aquatic director if you have questions. Weekdays between 4-7 PM often have swim team or group lessons and are generally unavailable for private lessons. Weekends tend to be ideal for pool availability. If your schedule is too restrictive you may not get picked up by an instructor.
Participant Name:*

First NameMiddle NameLast Name
Second Participant Name for Semi-Private Lessons:

First NameMiddle NameLast Name
Parent Name (if youth participant):*

First NameMiddle NameLast Name
Which branch would you like private swim lessons at?:

Chippewa Falls YMCAEau Claire Downtown YMCAEau Claire South YMCA
Phone Number:*

Area CodePhone Number
E-mail Address:*
Gender

MaleFemale
Date of Birth

MonthDayYear
Date
YMCA Member Status

Current MemberNon-Member
Number of Lessons Requested

1510
Days Available for Lessons:

SundayMondayTuesdayWednesdayThursdayFridaySaturday
Times Available for Lesson:
Date you wish to start

MonthDayYear
Date
Teacher Choice

Male TeacherFemale TeacherNo preference
Will outside funding or assistance (ex: county or state aid) cover the cost of private lessons?

Yes*No
*If yes, what county and social worker?
Swimming Ability: Describe participant's strengths/weaknesses - including any goals you wish to attain. Please include Swim Stage Level participated in:
I understand: I must provide 24-hour notice to cancel a private swim lesson; otherwise, I will lose the lesson. Lessons remaining after the agreed upon time period are forfeited. Filling this form does NOT guarantee me lessons. Swim lessons are picked up by instructors based on my availability. Aquatics staff will contact me to approve payment and schedule lessons.
Signature*
Date*

MonthDayYear
Should be Empty:

YMCA of the Chippewa Valley