Private Swim Lessons

Summer 2016

Private Swimming Lessons

July 2016 & August 2016

8 am - 4:30 pm

Lessons are 30 minutes each.

Price:

$120 for 4 private lessons per week
$150 for 5 private lessons per week

Swimmer's / Parent's Information
Child's Name	First	Middle	Last
Address	Street	City	Prov	Postal
Child's Date of Birth
Parent's Contact Info	Home Phone	Email
Child's Mother	Mother's Name	Hebrew Name	Work Phone	Cell
Child's Father	Father's Name	Hebrew Name	Work Phone	Cell
Emergency Contact	Name	Phone	Relationship
Pediatrician	Name	Phone

Swim Level

First come, first served!

Spots are only reserved upon advanced payment.

Please select the weeks and times that you would like your child to attend private swimming lessons.

Once a space has been booked it will be indicated on the form and you will no longer be able to book it.

Tuesday, July 5, 2016 - Friday, July 8, 2016
Price $120

Monday, July 11, 2016 - Friday, July 15, 2016
Price $150

Monday, July 18, 2016 - Friday, July 22, 2016
Price $150

Monday, July 25, 2016 - Friday, July 29, 2016
Price $150

Monday, August 1, 2016 - Thursday, August 4, 2016
Price $120

Monday, August 15 , 2016 - Friday, August 19, 2016
Price $150

Monday, August 22 , 2016 - Friday, August 26, 2016
Price $150

Total Cost:

Payment

•

All forms must be completed and submitted with payment.

Mastercard Exp.Date

Visa Exp.Date

Amex Exp.Date

Name on Card:

Security Code:

	Notes:
	Date of Application: