Private Swimming Lessons
Child’s Name: _____________________________________________________ ~Age: ____________
Parent Name(s): ____________________________________________________________________
Home Phone: ________________________________ Cell/Work: ____________________________
Email Address: ~_____________________________________________________________________
Medical Consideration(s): ____________________________________________________________
Emergency Contact and Phone #: _____________________________________________________
Fee: $25/ hour $15/ half hour
Please contact the instructor of your choice to set up the lesson day and time. Additional questions contact firstname.lastname@example.org 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:______________