Private Lessons Form

Parent’s Name

Parent’s Email

Parent’s Cell Number

Child’s Name

Child’s Previous Swimming Experience

Please list any allergies.

Are the child’s vaccinations up-to-date?
—YesNo

Does your child have any special needs or developmental delays that we need to take into account?
—YesNo
Please explain.

Child’s Physician Name

Physician Telephone Number

May we use your child’s photograph for our website and/or social media?
YesNo

I understand that private lessons are $85 for 30 minutes per child payable by cash, check (made payable to Jessica Kramer), or Venmo @Jessica-Kramer-23

I understand that payment is due at the time of the lesson-payable by cash, check (made payable to Jessica Kramer), or Venmo @Jessica-Kramer-23

I understand that there will be a $25 per-day late fee for balances not paid on time.

I understand that cancellations are 24 hours in advance.

I understand that if I fail to cancel 24 hours in advance I must pay for that day’s lesson.

Please type your first and last name if you affirm this statement. “I have enrolled my child in a swimming program of physical activity offered by Swimmers by Jessica. I hereby affirm that my child is in good physical condition and does not suffer any disability that would prevent or limit his/her participation in the program.”

Please type your first and last name if you affirm this statement. “In consideration of my child’s participation in Swimmers by Jessica, for my child, myself and assigns, I hereby release Swimmers by Jessica and it’s employees and owners from any claims, demands and cause of action arising from my child’s participation in this program.”

Please type in your first & last name if you affirm this statement. “I affirm that I have read and understand all the requirements listed above.”