Private Swim Lesson Registration
Swimmer's Name
*
First Name
Last Name
Parent's Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent's Email Address
*
example@example.com
Parent's Phone Number
*
Please enter a valid phone number.
Swimmer's Age
*
What would you like to work on?
*
What date/time would you prefer the first lesson?
*
How Many Lessons Would you like to purchase?
*
One (1) $125
Two (2) $250
Three (3) $350
Four (4) $450
Five (5) $550
Six (6) $650
Calculation
Total Due:
prev
next
( X )
USD
Description
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
Should be Empty: