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Swim Policy Form Adult 
Swim Lesson Program Policies and Registration Form 
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Name *

Date of Birth

 *
MM
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YYYY
Address *
Phone Number *
Email  *


EMERGENCY CONTACT: 

Name and phone number of person to reach in the event of an unlikely emergency (i.e. cell phone and/or destination).

 

 *

Pricing and Membership: 

Please select your preference for ratio:

A payment ensures one (1) 30-minute swim lesson that week.

 *
We work to schedule lessons within the preferred day and time, but it is not guaranteed.

Please indicate the day of the class that was confirmed with a member from The Therapy Gym
 *
Required
Please indicate the time of the class that was confirmed with a member from The Therapy Gym
Time
:
What is your experience with swimming? 
Have you ever taken swim lessons?
Clear selection
What are your goals for you to achieve in the swim program? *
Is there a specific teaching method your benefit from?
Is there anything else you'd like us to know about you?

Ex. special needs, anxieties, preferences, etc.
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