Swim School Private Instructor Booking & Intake Form
Please fill out all sections accurately to help us tailor the swimming lessons to your child's needs.
Important!
Before booking, please take a moment to read the “Things to Know Before You Book With Me” PDF.Just copy and paste the link below, then click on the “Things to Know Before You Book With Me” section.This document includes important details about policies, pricing, and what to expect during lessons! https://linktr.ee/MissHeatherSafeSwim
Child's Full Name
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First Name
Last Name
Child's Date of Birth
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Month
-
Day
Year
Date
Child's Age
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Child's Gender
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Male
Female
Other
Parent's Full Name
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First Name
Last Name
Parent's Contact Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Parent's Social Media Handles (e.g., Facebook, Instagram)
Child's Medical Conditions (if any)
Allergies (if any)
Current Medications (if any)
Developmental or Physical Delays (if any)
Parents' Goals for the Child in Swim School
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Any Concerns or Special Instructions
Use of Any Life-Saving Devices (e.g., Life Jackets, Flotation Devices)
How Did You Hear About Us?
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Friend Referral
Online Search
Social Media
Returning
If Referred by a Friend, Please Name the Friend (for Thank-You)
Child's Access to a Pool
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Own Pool
Community Pool
Family Pool
None
Frequency of Swimming Outside Class
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Daily
Weekly
Occasionally
Rarely
Consent for Use of Child's Photos/Videos on Social Media
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I Consent
I do not consent
PLEASE READ: How Booking with Me Works
To make the booking process easy and fair for everyone, here’s how it works: You are booking for the upcoming session that starts on Monday, July 21st.This session runs for two consecutive weeks, Monday through Friday, for a total of 10 private lessons. Week 1: July 21st – July 25th Week 2: July 28th – August 1st ✅ Please note: The official start date is Monday, July 21st. Booking this session means you are committing to that start date and the full two-week schedule. 1. Give a 2-Hour Time Window: In the box below, write a 2-hour time window that your child is available every day (Monday–Friday) during the above two weeks. 2. Wait for Confirmation: Once you submit this form and payment, I will choose a lesson time that works for me within your 2-hour window, and I’ll text you your confirmed lesson time Here is an Example of what you can write in the box below: “We’re available to start on July 21st and can come between 3:00 PM and 5:00 PM each day for the full two weeks.” Then, I’ll send you a confirmation message that looks something like this:“Your child’s lesson time will be 4:30 PM each day for the two weeks.” Thank you for helping me keep the scheduling process smooth for everyone!
Book Here!!! (Read above on how to Book)
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Optional: Book a phone call before your session if you'd like to discuss details in advance
If you’d like to talk or go over any details about your child’s lessons ahead of time, just check the box below, and I’ll reach out to set up a time to chat before your child’s first session.
Yes i would like to book a phone call in advance
Pricing Agreement
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By checking this box, I acknowledge and agree to the total price of $375 for ten (10) consecutive private swim lessons. I understand this fee is due in full prior to the start of lessons and is non-refundable.
Payment Acknowledgment – Zelle Required Before Submission
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By checking this box, I acknowledge and agree to send full payment via Zelle to Miss Heather at (661) 373-8107 before submitting this form. (The Zelle account will appear as “Terrific Kids Day Care” – this confirms you have the correct recipient.) I understand that if payment is not completed prior to submission, my booking will be canceled and my spot will not be guaranteed.
Booking Terms & Conditions
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By checking this box, I acknowledge and agree to the following: Due to high demand and limited availability, all swim lesson bookings are final. No refunds or makeup lessons will be provided under any circumstances. This includes, but is not limited to, scheduling conflicts, missed lessons, or dissatisfaction with the teaching style or swim program structure. I understand and accept the swim philosophy as outlined, and I am choosing to proceed with full awareness of this policy.
Parent's Signature
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First Name
Last Name
Date of Signature
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Hour Minutes
AM
PM
AM/PM Option
Did you send your Zelle payment?Please confirm below:
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Yes, I have sent the $375 payment via Zelle to (661) 373-8107
Once you submit this form with your payment, I’ll send you a confirmation text with your child’s official lesson dates and time, along with a detailed welcome message so you know exactly what to expect and how to prepare for their swim lessons.
Submit Booking & Intake Form
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