Order Number Student First Name: * Student Last Name: Student DOB: * Parent/Guardian: * Do you prefer a private or group lesson? * Phone: * Email: * Would you describe your swimmer as: * Beginner (working on floating independently) Intermediate (can swim 10+ feet with eyes in the water) Advanced (can swim a full length of multiple strokes) Would you describe your swimmer as: Nervous In-Between Eager Other If Other: What are your goals for swimming lessons? Is there anything we should know about your child as a swimmer or as a learner? Does your child have any medical conditions that may affect swim lessons? Does your child have any conditions that may require special care?