Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Type of Lesson
*
Adult
Child
Swimmers Name
*
Date of Birth
*
/
Day
/
Month
Year
Date
Current Swimming Level
*
No swimming experience
Non Swimmer - (Ducklings/stage 1)
Beginner - (stage 2 - stage 3)
Improver - (stage 4 - stage 6)
Technique Lessons
Looking to Improve for a Sporting event
Any Medical Conditions
*
None
Asthma
Escma
Food Intolerance
Grommets
Suffers from Nose Bleeds
A.S.D
A.D.H.D
Downs Syndrome
Hearing Impairment
Sight Impairment
Hypermobility
Dyspraxia
Cerebral palsy
Other
Does your child attend mainstream school/nursey
*
Please Select
Yes
No
Not in School/nursey yet
Do they require 1-to-1 support in school/nursey
*
Please Select
Yes
No
Not in School/nursey yet
Which venue are you looking for lessons
*
First Step Gym, Corsham (Tuesday, Thursday)
Stonar School, Atworth (Sunday)
Seahorse Hydrotherapy Pool, Trowbridge (Tuesday, Thursday, Sunday)
How did you hear about us
*
Word of mouth
Referred by a friend
Facebook
Instagram
Leaflet
Web Search
Other
To stay updated on our latest offers, exclusive discounts and swimming tips, please sign up for our newsletter
*
Yes - Sign up
No - Don't Sign up
Message to the Team
Ask about lessons
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