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Intake form
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Name
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Email address
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What is your age group?
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Under 5
6-10
11-15
16-20
21-30
31-40
41-50
51 and above
What is your swimming experience level?
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Beginner
Intermediate
Advanced
What type of swimming lessons are you interested in?
Please select at least one option.
Learn-to-Swim
Stroke Correction
Swim Squad Program
Lifeguard Certification Training
Do you have any medical conditions that we should be aware of?
What days are you available for lessons?
Please select at least one option.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What time of day works best for you?
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Morning
Afternoon
Evening
How did you hear about SwimChicken?
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Social Media
Friend/Family
Search Engine
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Which service or services are you interested in?
Please select at least one option.
Survival skills
Learn-To-Swim
Stroke correction
Swim squad program & lifeguard certification training
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