Rose - Private Swim Lessons | Butler County Family YMCA

Private Swim Lesson Intake Form

For Rose E. Schneider Family YMCA only.

Parent/Guardian's First Name

Parent/Guardian's Last Name

Child's First Name

Child's Last Name

Date of Birth

Address

Address 2

City/Town

ZIP/Postal Code

Email Address

Phone Number

Are you a member of the Rose E. Schneider Family YMCA

Have you ever participated in our YMCA group swim lesson program?

What was the last group swim level your child completed?

Briefly explain your ability level in the water (ex: can swim a specific distance with face in or out of water)

Do you have any specific needs we should be aware of in order to enhance the quality of your experience?

Please indicate your availability. Include day of week and time frame available. Listing several days & time frames will give you the best opportunity to be assigned to an instructor.

Please note that Private Lessons WILL NOT be scheduled during our Group Lesson times.

NO SHOW POLICY

If you do not show up or give your instructor at least 24 hours notice, you will be deducted one of your seven lessons. By signing below, you agree to the NO SHOW POLICY.

Signature

Sign above