Private Lesson Request Form

If you are interested in a private or semi-private swim lessons please fill out this request form. Our Aquatics Coordinator or one of our swim lesson instructors will contact you to schedule your first lesson!

Questions?

Contact Aquatics Coordinator, Alicia Richmond
Alicia.Richmond@parkersburgymca.org

Student's Name

First Name

Last Name

Private Lesson Type

Private Lesson

Semi-Private Lesson

Student's Date of Birth

YYYY

Swim Level

Availability

Daytime

Evenings

Weekends

Parent/Guardian Name

Only if under 18

First Name

Last Name

Phone

(###)

###

####

Is there anything you would like us to know?