East Carolina University Campus Recreation & Wellness
Private Swim Lesson Request Form
Participant’s Information
Banner ID #_______/______/__________ Participant’s Name____________________________________
(First)
(MI)
(Last)
Today’s Date:________________________Phone: (____)_______________E-mail:_______________________
Address:___________________________________________________________________________________
(street address)
(city)
(state)
(zip)
Age:__________
Responsible Adult:___________________________________________
(If participants is under 18 years of age)
What days and times would be best for a half hour lesson:_______________________________
______________________________________________________________________________
What is the participant’s level (check one):
______
Beginner
______
Intermediate
_______
Advanced
Please list any special concerns:__________________________________________________
Please circle the number of swimming lessons you would like to register for.
2 lessons @ $30
4 lessons @ $50
6 lessons @ $75
8 lessons @ $95
Private Swim lesson’s polices





All private lessons are to be established through the Coordinator of Aquatics for the SRC.
All lessons are 30 minutes, unless pre-approved by the Coordinator of Aquatics.
Cancellations must by done at least 4 hours ahead of scheduled lesson, by calling the instructor and the
Coor. of Aquatics to reschedule lesson. If prior notification is not received, the credit for that lesson is
forfeited.
Participants need to be appropriately dressed and ready to participate at arranged starting time.
Participants must be at least four years of age at the start of the first lesson
____________Do Not Write Below This Line/For Office Use Only______________________
Assigned Instructor:_____________________________ Phone #:______________________
Schedule(date/time): ________/________
________/________
________/________
________/________
________/________
________/_______
________/________
________/________ Cancellations/reschedules: ________/________
Amount Paid __________
Date Paid_____________
________/________
Staff Initials_______________