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General
Host Parent Name:
Host Pool Address:
City:
State:
Zip:
Metro Area:
Major Cross Streets: /
Home Phone:
Cell Phone:
E-mail Address:

Children

Days & Times Desired
Lesson Begin Date:
Days:
Hours:

Notes
Known client vacations for instructor awareness:
Parent Notes for Our Office:
Student Special Needs. Cuurent Swimming Level, Fearful, etc:

Lessons
Minutes / Day:
Travel Stipend: $5 per lesson, and $20 per child annual registration fee applied.
Lessons:
Total Paid this Lesson Order: $0