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Private Swim Lesson Request Form
Hi there, please fill out and submit the Private Swim Lesson Request form.
12
Questions
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1
Name
*
This field is required.
First Name
Last Name
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2
Name of Participant
*
This field is required.
Only fill out if different than registering party.
First Name
Last Name
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3
Email
*
This field is required.
example@example.com
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4
DOB of Participant
*
This field is required.
-
Date
Month
Day
Year
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5
DAWG Tag (if applicable)
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6
Phone Number
Phone Number of Participant
Phone Number of Guardian (if applicable)
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7
Emergency Contact
*
This field is required.
Emergency Contact Name
Emergency Contact Phone Number
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8
Level of Experience
0 being least, 5 being most
0
1
2
3
4
5
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
0
1
2
3
4
5
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
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9
Instructor Preference
Name of Instructor
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10
Preferred Language
What language do you prefer the lesson to be taught in
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11
Time/Day Preference
*
This field is required.
Time
Day
1.
Row 0, Column 0
Row 0, Column 1
2.
Row 1, Column 0
Row 1, Column 1
3.
Row 2, Column 0
Row 2, Column 1
1.
2.
3.
Time
Row 0, Column 0
Day
Row 0, Column 1
Time
Row 1, Column 0
Day
Row 1, Column 1
Time
Row 2, Column 0
Day
Row 2, Column 1
1
of 3
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12
Additional Comments
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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Should be Empty:
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