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Private Swim Lessons

Private Swimming Lessons

Child’s Name: _____________________________________________________ ~Age: ____________

Address: ____________________________________________________________________________

Parent Name(s): ____________________________________________________________________

Home Phone: ________________________________ Cell/Work: ____________________________

Email Address: ~_____________________________________________________________________

Medical Consideration(s): ____________________________________________________________

Emergency Contact and Phone #: _____________________________________________________

Fee: $25/ hour $15/ half hour

Caroline Pisinski @

Rose O’Halloran @

Sean Scannell  @

Please contact the instructor of your choice to set up the lesson day and time.  Additional questions contact or 508-886-0048

I agree not to hold responsible the Rutland Recreation Committee, the Town of Rutland;, or any of the parties connected with this program for any accident or injury that may occur during the program. I understand that if my child becomes a discipline problem, he/she will be dismissed from the program without a refund. I also grant permission for the Recreation Staff to seek medical care for my child in the event that I cannot be reached.  
The cancellation/refund policy will be strictly enforced.

Parent or Guardian Signature: ______________________________________________________

check #: ______________ date:______________ amount:______________

Town of Rutland 250 Main Street, Rutland, MA 01543   Disclaimer
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