First Name
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Last Name
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Email
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Phone
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Who are you interested in getting into swim lessons?
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My Child(ren)
Myself
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How many children?
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1
2
3
4
Myself
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Date of birth for whoever is interested in lessons:
Additional Birthdays
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Does the person interested in lessons have any special needs/disabilities?
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Yes
No
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What type of special needs/disabilities?
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If yes, please tell me you/your child swimming knowledge and water comfortability
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What type of lessons are you/your child interested in?
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Private
Semi-Private
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Have you/your child ever had swim lessons?
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Yes
No
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Any major negative water experiences or fear of the water?
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Would you like to be on my cancelation list for fill in lessons? These are when my clients have absent days, call in sick or I have a cancellation.
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Yes, I would come for fill in lessons when there is availability
No, I want to wait for a regular weekly spot
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