Chinn Individual Swim Lesson Request Form

1. Today's Date *This question is required. This question requires a valid date format of MM/DD/YYYY.

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2. Student Name(s) *This question is required.

3. Gender *This question is required.

4. Date of Birth *This question is required.

5. Age *This question is required.

6. Parent's Name (if student is under 18)

7. Home Phone *This question is required.

8. Adult Cell *This question is required.

9. E-mail Address *This question is required. This question requires a valid email address.

10. Expectations for individual swim lessons