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Number of Students:
Student Name:
Student Age:
Student Birthday:
Parent's Name (First,Last):
Mailing Address:
City:
Zip:
Home Phone:
Cell Phone:
Work Phone:
Email Address:
Preferred Lesson Day & Time:
Pool Location:
Bascom Pool
Lesson Type:
15 minute Private (1 Student)
30 minute Private (1 Student)
Semi-Private (2 Students)
Group (3 Students)
Big Fish/Little Fish (8 Students)
Adult Group (3 Students)
"Maki Moms" (3 Students)
Past Maki Student?:
Yes
No
Comments: