Private Swim Lesson Registration

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:

USD Description