MCGAW YMCA AQUATICS
Private Swim Lesson Request Form
A. Personal and Family Information
Participant Name: _________________________________________________________ DOB: ___________________________________ Gender:
M
F
Address: ______________________________________________________________________ City: ___________________________ State: ______________ Zip: ___________
Parent/Guardian Name: __________________________________________________ Email: ___________________________________________________________________
Home Phone: _____________________________________ Work Phone: ___________________________________ Cell Phone: ________________________________
Additional Participant(s): ________________________________________________ DOB: ___________________________________ Gender:
M
F
B. YMCA Membership Status
 McGaw YMCA Member  Non-member Student’s current membership status: C. Lesson Registration (please check one)
Private Lesson (1 or 2 participants)
 1 Lesson
 5 Lessons
30 minutes
30 minutes
Fee: $40 member/$60 non-member Fee: $170 member/$270 non-member Check your swimming ability:
Beginner
Intermediate
Advanced
Name a specific swim instructor you would like (if you are unsure, leave blank) _______________________________________________________
Would you prefer a male or female instructor?  Male  Female  No preference Which pool would you prefer?  4 - Lane  6 – Lane If you chose 4 Lane Pool, what day(s) of the week are you normally available to meet with an instructor? *Please Note: Not all times are available. Times of lessons will be based upon availability of the pool and the instructor* Sunday
8am–9am
10am–12pm
2pm–4pm
Monday
7am–9:45am
12:50pm-6pm
Tuesday
7am–10am
12:50pm–4:00pm
4:45pm–7pm
Wednesday
7am–9:45am
12:50pm–4:45pm
Thursday
7am–10am
12:50pm–3:30pm
4:30pm–7pm
Friday
7am–11am
12:50pm–4:45pm
8pm–9pm
Saturday
7am–12pm
2pm–4pm
If you chose 6 Lane Pool, what day(s) of the week are you normally available to meet with an instructor?
*Please Note: Not all times are available. Times of lessons will be based upon availability of the pool and the instructor*
 6am – 9am  9am –12pm  12pm – 3pm  3pm – 6pm  6pm – 9pm
What are your swimming goals? _________________________________________________________________________________________
D. Payment
Total amount enclosed: $ ___________
Method of Payment:  Check (Please make checks payable to The McGaw YMCA)  Visa  MC
Credit Card #: __________________________________________________________________ Exp date: ____________
Name on CC: ___________________________________________________________
Billing Zip: __________________
 Discover
 AMEX
In signing this form, I understand that:

No-shows or cancellations received less than twenty-four (24) hours before a scheduled appointment will be charged to the client.

No refunds are given for missed/unused private lessons

Lessons must be scheduled within 3 months from purchase date and used within 6 months of the purchase date.

The participant is expected to be punctual and understand that the instructor may have appointments immediately preceding or
following their appointment. The instructor is not obligated to stay past the allotted time scheduled for the appointment.

To qualify for the member rate all participants must be members of the McGaw YMCA.

No more than 2 participants are allowed per private swim lesson
I HAVE READ AND AGREED TO ALL REQUIREMENTS ON BOTH SIDES OF THIS FORM
Adult Signature: _________________________________________________________________________________________
Date: _____________________________________________
Payment Requirements, Instructions, and Important Information
Please read prior to registration
Please read the following instructions and policies. Then, fill out the Aquatics Private Lesson Registration Form and return it
with payment to Membership Office or the Aquatic Manager.
A. Personal and Family Information
Please fill out student information and (if the participant is a minor) parental contact information. Please try to give us as
much information as possible, including email information.
B. YMCA Membership Status
Please check whether you are a McGaw YMCA member or a Non-Member. If you are participating in a semi-private lesson,
then both participants need to be a member of the McGaw YMCA in order to qualify for the member rate.
C. Lesson Registration
Please complete this section indicating:




The type of private lesson preferred
Swimming ability and instructor
Which pool you prefer
Time frame of which you would like to take your lesson
The Aquatic Manager or an instructor will call to confirm this information and set up lesson times once we have received your
registration form.
Please be aware that times are assigned on a first-come-first-served basis and we cannot guarantee the lesson time you
choose will be available. However, we'll do our best to accommodate you as much as we can.
D. Registration Payment
In order to register for private lessons, this form must be returned to the Membership or Aquatics Office with payment. You
may use checks, Visa, MasterCard, Discover, or American Express credit/debit cards, or cash. Lessons will not be given until
full payment is received prior to the participant’s first lesson.
Other important information about private lessons






No-shows or cancellations received less than twenty-four (24) hours before a scheduled appointment will be charged to
the client.
No refunds are given for missed/unused private lessons
Lessons must be scheduled within 3 months from purchase date and used within 6 months of the purchase date.
The participant is expected to be punctual and understand that the instructor may have appointments immediately
preceding or following their appointment. The instructor is not obligated to stay past the allotted time scheduled for the
appointment.
To qualify for member rate on a private lesson with 2 participants, both participants must be a member of the McGaw
YMCA.
No more than 2 participants are allowed per private swim lesson
Membership waiver, Photography Release and Required Signature
In applying for YMCA membership and/or program participation, I agree to cooperate with others in supporting the YMCA
mission goals and objectives and to abide by policies and procedures set forth by the McGaw YMCA Board of Directors. I do
hereby agree to hold free from any and all liability the YMCA and its officers, employees, and members and do hereby myself,
my heirs, executors and administrators waive, release and forever discharge any and all claims for damages which I may incur,
or which hereafter accrue to me, arising out of or connected to my participation in any of the activities of the YMCA. I give
permission and consent to the use of any photograph, videotapes or in other media record of my child’s participation at the
McGaw YMCA for any lawful purpose, without compensation on my behalf. If I choose not to have my child photographed,
videotaped or in other recorded media, it is my responsibility to inform the photographer. My signature below authorizes the
credit card charges designated above.