Private Swim Lesson Registration Form (Adult)

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Registration Date
Participant's Name
Home Phone
Alternate Phone
Preferred Method of Contact Home Phone Alternate Phone Email
How many swim lessons would you like to purchase? Single Lesson 5 Pack 10 Pack
Instructor Preference: Male Female No Preference

What best describes your current swim level? Cannot Swim Beginner Intermediate Advanced

Do you have any fear of the water? YES     NO
Do you have any health concerns or other concerns that you would like noted?

What goals do you hope to achieve with the swim lesson(s)?

What days and times are you available for lessons?

How did you hear about our swim program?


Please stop by the Dedman Center for more information or contact Lindsey Gavlick at 214-768-9916 or


Recreational Sports is a department in the Division of Student Affairs.