Childs First Name * Childs Last Name * Childs Age * Childs Gender * Male Female Parent/Guardian First Name * Parent/Guardian Last Name * Street - (Mailing Address) * City - (Mailing Address) * State - (Mailing Address) * Zip Code - (Mailing Address) * Phone Number * Alternative Phone Number Email Address * Please list any specific goals you would like to see accomplished throughtout these private lessons * Have you previously been enrolled in private swim lessons at the Falcon Center? * Yes No Price Packages * One Lesson Package - $25 Five Lesson Package - $105 Eight Lesson Package - $160 Availability For Lessons * Please list which days of the week you are available to meet for lessons along with times of each day. Please keep in mind that the lesson must occur during open hours of the aquatic facility. To view the pool hours, please visit: http://www.fairmontstate.edu/falconcenter/about-us/falcon-center-hours Confirmation * I have read and understand the contents and the consequences stated in this notification. I also understand that this is a request submission and that I am not enrolled in the course until complete payment is received by Fairmont State University and they have contacted me as enrolled.