Private Swim Lessons Request Form LinkedInThis field is for validation purposes and should be left unchanged.This field is hidden when viewing the formDate(Required) MM slash DD slash YYYY Participant's Name(Required) First Last Participant's Age(Required)Parent/Guardian's Name(Required) First Last Email(Required) Phone(Required)Lesson Type Desired(Required) Private Semi-Private How many lessons would you like to purchase?Preferred Day/TimePlease note that private swim lessons are on a first-come first-serve basis. We will try to accommodate preferred days/times to the best of our ability.Dates unavailable due to other commitments/vacation:Instructor PreferenceSwimming Ability & GoalsSwimming Ability(Required) Non-Swimmer Beginner Intermediate Advanced Ability Details (Non-Swimmer)Check all that apply Will not put face in water Can blow bubbles in water Is comfortable in water WITH flotation Is comfortable in water WITHOUT flotation Can float on back with support Can float on front with support Ability Details (Beginner)Check all that apply Can jump into water Will submerge underwater Can demonstrate front crawl stroke Can demonstrate breaststroke Can demonstrate elementary backstroke Ability Details (Intermediate)Check all that apply Can edge dive Can demonstrate survival float Can tread water for 3 min. Can swim 25 yds (1 lap pool length) Can swim 25 yds in Backstroke Can swim 25 yds Breaststroke Can Swim 25 yds Front Crawl Can swim 10 yds Butterfly Ability Details (Advanced)Check all that apply Can surface dive Can tread water for 10 min Can demo flip-turn Can proficiently swim 25 yds. in Backstroke Can proficiently swim 25 yds. in Breaststroke Can Swim 25 yds. in Front Crawl Can proficiently swim 25 yds. in Butterfly Please describe goals for the class:Special RequestsOther lessons/classes you would like to see at Fraser Valley Rec:Health InformationDoes swimmer have any of the following? Tubes in ears Epilepsy Special needs Asthma Diabetes Allergies