These lessons are available at a first come first serve basis. Special arrangements and instructor availability will determine exact times and dates. Please note: All swim lessons are NON-REFUNDABLE. Personal Information Parent or Guardian Name (If Applicable) Participant Full Name Preferred/Nickname Participant Age Address Address Address 2 City/Town State/Province State/Province Alabama Alaska American Samoa Arizona Arkansas Armed Forces (Canada, Europe, Africa, or Middle East) Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ZIP/Postal Code Cell Phone Number Email Emergency Contact Information Emergency Contact 1 Name Address Address Address 2 City/Town State/Province State/Province Alabama Alaska American Samoa Arizona Arkansas Armed Forces (Canada, Europe, Africa, or Middle East) Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ZIP/Postal Code Phone Number Email Emergency Contact 2 (If Applicable) Name Address Address Address 2 City/Town State/Province State/Province Alabama Alaska American Samoa Arizona Arkansas Armed Forces (Canada, Europe, Africa, or Middle East) Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ZIP/Postal Code Phone Number Email Swim Experience What is the participant's level of swim experience? Please select the answer best describing the participant. Not comfortable in water Requires life jacket Can float on their own Been in swim lessons before Can swim in shallow end Can swim in deep end In 2-3 sentences please describe your goal for the lessons. This description will help us match the participant with the instructor that is best able to help! If you have a preferred instructor, please type their name below. Availability Please select the times that you are available. (You can select more than one option) Early Morning Morning Noon Afternoon Early Afternoon Late Aternoon Evening Please describe your availability including what days and times you are available for lessons. Please give as wide a range as you can! Leave this field blank