Aquatics Private Lessons Request Form- Mark Lenzi Pool

Stafford County Aquatics Private Lessons- Mark Lenzi Pool 2026 Private lessons are on a first-come first-served basis and run on a monthly schedule. Submission of this application does not guarantee your lessons are scheduled. Staff will contact you regarding your application and payment.
Main Contact*

First NameLast Name
Student's Name*

First NameLast Name
Email*
example@example.com
Age of participant*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date Submitted*

MonthDayYear
Date
MondayTuesdayWednesdayThursdayFridaySaturdaySunday
10-10:30 am10:30-11 am11-11:30 am11:30-12 pm12-12:30 pm12:30-1 pm1-1:30 pm1:30-2 pm2-2:30 pm2:30-3 pm3-3:30 pm3:30-4 pm4-4:30 pm4:30-5 pm
8:30-9 am9-9:30 am9:30-10 am10-10:30 am10:30-11 am11-11:30 am11:30-12 pm12-12:30 pm12:30-1 pm1-1:30 pm1:30-2 pm2-2:30 pm2:30-3 pm3-3:30 pm3:30-4 pm4-4:30 pm4:30-5 pm
Please list participant's skill level, swimming experience, special requests and instructor preference:*
YesNo
Accommodation Request: We welcome individuals with diagnoses that include physical or cognitive disabilities in our recreation programs and strive to provide an inclusive environment. Inclusion services and reasonable accommodations are available to ensure positive and successful participation. If inclusion services or accommodations are requested an Inclusion Support Request Form must be submitted before the start of any program. If you require a reasonable accommodation or modification, please respond YES. Then complete and return the Recreation Inclusion Support Request Form to ssprague@staffordcountyva.gov. Form must be returned prior to the start of program/class. If you do not require an accommodation or modification, please respond NO.*

YesNo
WAIVER FOR PARTICIPANT: By signing this form, I desire, consent, and voluntarily choose to allow the individual(s) named herein to take part in all such activities. Knowing the material risks and appreciating, knowing, and reasonably anticipating that other injuries and death are possibilities, I assume all the risks normally incident to the nature of the activities and agree that neither the Stafford County Dept. of Parks and Recreation nor the County of Stafford, VA will be responsible for any damages or injuries resulting to me or my child.

Therefore, having read and understood this waiver and in consideration of your accepting my entry into a Stafford County recreation facility, program, or activity, I, for myself and my child, waive and release the County of Stafford, VA and its officers, staff, volunteers, sponsors, and representatives from all claims or liabilities of any kind arising out of my participation in (or as a spectator of) any program, activity, or use of any County facility.
Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
Private lessons are based on our American Red Cross Water Safety Instructor (WSI) availability. Staff will contact you within 3 weeks of your application to schedule the lesson.
Should be Empty:

Stafford County Aquatics Private Lessons- Mark Lenzi Pool 2026 Private lessons are on a first-come first-served basis and run on a monthly schedule. Submission of this application does not guarantee your lessons are scheduled. Staff will contact you regarding your application and payment.