Private Swim Lessons Request Form

Contact Information

Student First Name

Student Last Name

Address 1

City

State

Postal Code

Phone

Date of Birth

Parent/Guardian Name:

Current Thoreau Club Member?
(select all that apply)

Yes

Previous swimming experience?
(select all that apply)

Yes

How did you hear about us?
(select all that apply)

Online search

Social media

Referral

Other (Please specify in the comment section below)

Comments for Aquatics Staff

* Bold Fields are Required

First Name*

Last Name*

Phone

Comments