Private Lesson Request

Please complete and submit this form. An instructor will contact you to set up dates & times.

Please select what type of lesson you would like to register for:

Private lesson single
Semi-private single Private lesson series (4 half-hour lessons)
Semi-private series (4 half-hour lessons)

Contact Information:

Student's Last Name:
First Name:



Birthday:
(mm/dd/yyyy) Gender:
Female Male



Parent's name, if applicable:



Primary Phone:
999-999-9999 Secondary Phone:
999-999-9999



Address 1:



Address 2:



City:
State:
Zip Code:



Email:



If you are requesting semi-private lessons, please give us the name and birthdate of the other person. (Students from other families also need to submit their information).



Lesson Content:

Level of experience/comfort (check all that apply):

None Very Anxious Fearless

Some Lessons Uncomfortable in water Developing strokes

Swims but isn't pretty Good swimmer Needs technical work



Specific requests? Please let us know what area in particular you would like to cover in lessons:



Scheduling: (Please check all Days that apply in conjunction with the Possible Times)

Possible Days:

Any Mon Tues Wed Thurs Fri Sat Sun



Possible Times:



Program Pool Availability -

  Mon-Thu: 7AM-4PM, 8PM-9PM; Fri: 7AM-4PM; Sat: noon-6PM (Close); Sun: 1-6PM (Close)

Instructional Pool Availability -

  Mon-Fri: 7AM-4PM; Sat: 3PM-6PM (Close); Sun: Not Available



Instructor preference, if applicable. Name:
If you have no instructor preference, we will do our best to match you with an instructor for your needs and schedule.



Policies and Procedures:
Guests for private lessons must sign in at the front desk at each visit.
Full payment is due at the first lesson, for a single lesson or for a series.
24 hour advance notice for any cancellation or change request must be sent in writing to both the instructor and to jherman@triangleaquatics.org, or the lesson will be charged in full.
Same-day changes or guest no-shows will be charged full fees.
Cancelling a series midway will incur a $10 cancellation fee.
Triangle Aquatic Center will notify all guests as soon as possible about any closures and cancellations.



Waiver: I hereby recognize and acknowledge that my or my child’s participation in recreational activities may involve bodily and/or emotional injury to myself and/or my child. In consideration of myself and my child being able to participate in such events, I, for myself, child(ren), heirs, executors and administrators, hereby voluntarily and knowingly indemnify and hold harmless, defend, release, waive, and discharge Triangle Aquatic Center and its officers, employees and volunteers from any and all suits, claims or liability, including negligence, based on any injury. Therefore, I agree to pay for medical, hospitalization or any other expenses resulting from my or my child’s participation.



I herby authorize Triangle Aquatic Center staff to act on my behalf in accordance with their best judgment in case of an emergency involving me or my child(ren), and agree to assume full responsibility for all expenses, medical or otherwise, that may arise there from. PHOTO RELEASE: I authorize Triangle Aquatics to use my image taken in classes for publicity purposes.



I Agree    I Agree