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Branch
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Please Select
Dowd YMCA
Keith Family YMCA
Lake Norman YMCA
Lowe's YMCA
Morrison YMCA
Simmons YMCA
Stratford Richardson YMCA
Participant first name
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Participant last name
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Gender
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Please Select
Male
Female
Birthday
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Age
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Please Select
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Street address
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City
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State/Region
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Zip code
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Email
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Phone number
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Referred by
*
Please Select
Family
Friend
Close to home
Internet
Other
Instructor preference
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Please Select
Female
Male
No preference
Specific instructor
Any conditions that the instructor should be aware of?
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Please list illnesses, allergies, diverse abilities or other.
Type of Request
*
All Semi Private and Mini Group lessons must find their partner participants (Ex.: sibling, friend, etc.)
Private Lesson (1 Instructor / 1 Student)
Semi-Private (1 Instructor / 2 - 10 Students)
Mini Group (1:3 Instructor: Student) - (at select branches)
Self assessment
*
Non-swimmer (Uncomfortable in water)
Non-swimmer (Comfortable in water)
Beginner (Can swim 10-15 feet and can float on stomach with face in water.)
Intermediate (Comfortable in water and can swim one pool length)
Advanced (Very comfortable in water and can swim 50 yards-two pool lengths)
Purpose of private swim lesson
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Goals
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Basic Water Acclamation
Breath Control
Buoyance (floating on front/back)
Treading Water
Jumping into deep water and recovering to the surface
Freestyle
Sidestroke
Backstroke
Elementary Backstroke
Breaststroke
Butterfly
Standing Dive
Other
Preferred Swim Lesson Times (AM)
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred Swim Lesson Times (PM)
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Do you have any health conditions or important information we need to better serve your needs and find you the right program?
*
Yes
No
Any additional information?
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