Private Swim Lessons – North Location
Name___________________________________________________________________
Parent’s name (if lesson is for a minor) ________________________________________
(Or other appropriate contact name/guardian)
Phone Number_________________________ Cell Number_______________________
Best time to call_________________________ Age: ___________ Gender___________
What level best describes the swimmer’s current abilities?
Level I
Inexperienced swimmers that are unable to swim or float without assistance. Some at this level are uncomfortable in the
water. Skills may include water awareness, water safety, entering and exiting the pool, kicking skills, breath control,
submersion and jumping in to instructor.
Level II
Swimmers that are comfortable in and under the water. Most are able to float unassisted at this level, they may or may not
be able to swim or “paddle” unassisted. Skills as this level may include water safety, head bobs, rhythmic breathing, arm
movements, floating on front and back, combining kicking and arms.
Level III
Swimmers that are able to float unassisted on both front and back. These swimmers are able to swim short distances of 5 to
15 meters. Skills may include water safety, beginning stroke techniques for freestyle, elementary back, and backstroke.
Level IV
Swimmers that have mastered “basic” swimming skills, they are able to skillfully swim distances of 25 to 50 meters. Skills
may include water safety, stroke techniques for breaststroke, sidestroke and butterfly, sculling, and treading water.
Level V
Swimmers that have knowledge of all major strokes, they are able to skillfully swim distances of more than 50 meters. This
level would focus strictly on enhancing stroke techniques with emphasis on speed and endurance.
Further comments on swimmer’s skill level and/or goals (optional):
(use back of page if needed)
When are you available for lessons?
Day:
Monday Tuesdays Wednesdays Thursdays
Time: Mornings
Afternoons
Evenings
Fridays
Saturdays
Sundays
Specific time range? ___________________
Instructor Preference? ___________________________________________________________
 Check here if you are a Bob’s Gym Member
 Check here if you are a Non-member
For more details contact Aquatics Supervisor, Severin Birchler 402-2627 ext. 1922 or e-mail
[email protected].
Member Prices, 30 minute lesson
Private - $16
Semi-private, two swimmers - $24
Semi-private, three swimmers - $32
Non-member Prices, 30 minute lesson
Private - $20
Semi-private, two swimmers - $30
Semi-private, three swimmers - $40
North Location
Guest Account Information
For swim lessons without a Bob's Gym membership please fill in information below to create a
guest account. (If you have not done so already).
Name on Account: ________________________________________________________
(parent/guardian name)
Date of Birth: ____________________________________________________________
(of name on account – parent/guarding)
Phone Number:__________________________________________________________
Address: _______________________________________________________________
City__________________________State_______________ ZIP___________________
Emergency Contact:
Name: __________________________________________________________________
Phone Number: __________________________________________________________
Signature required:
I accept full responsibility for my and/or my child's use of any and all apparatus,
appliances, facility privilege or service whatsoever, owned and operated by this Club at my own
risk and shall hold this Club, its shareholders, director officers, employees, representatives, and
agents harmless from any and all loss, claim, injury, damage or liability sustained or incurred by
me and/or my child resulting therefrom.
Signature: ____________________________________________ Date:______________
Employee Info: Enter above information into CSI as a guest.
Initial after entering into CSI ____________