Private Swim Lessons Request Form

Primary Member/ Parent Name*

First

Last
Are you a YMCA of Metro North Member?*
At which Branch would you like private lessons?*
Primary Member/Parent Phone Number*
Primary Member/Parent Email*
Select the Lesson Package you are interested in*

(Private Lessons: 1 individual)
(Semi-private Lessons: 2-3 individuals)
Instructor Preference*
Days Available*
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
- Sunday
Times Available*
What age is the participant?
Please list any goals you'd like to achieve during private lessons.
Please list/explain any limitations or disabilities that will help us customize your program.
Additional Comments