Adult Swim Lesson Registration

Name *

First

Last

Date of birth

Age

Gender

Male
Female

Address

Address Line 1

Address Line 2

City

State

Zip Code

Are you an employee?

Yes
No

Home

Work

Cell

Which number is best to contact

Home
Work
Cell

Email *

Instructor Preference for Private and Semi-Private (if any)

Time Preference

AM
PM

Member (4/30 Min. Lessons)

Private - $150.00
Group - $120.00
I'm a non-member

Non - Member (4/30 Min. Lessons)

Private - $170.00
Group - $140.00
I'm a member

How would you like to pay (We will reach out for payment after form has been submitted)

PAC Account **Preferred**
Check (Check must be brought in to hold spot) | Must be paid in 48 hours to hold
Cash | Must be paid in 48 hours to hold
Credit Card | Must be paid in 48 hours to hold

Payment must be made to ensure your spot

Signature *

Clear Signature

I accept full responsibility for my use of any apparatus, appliances, facility privileges, or service whatsoever owned and operated by this club, directors, officers, employees, representatives, and agents harmless from any and all loss, claim, injury, damage, or liability sustained or incurred by myself, my family or other under my supervision or control resulting therefrom. In addition, I agree that the above information is accurate and complete. I also understand and acknowledge that photos/videos may be taken for publicity/marketing purposes and give my authorization for any and all photos or video footage of myself, or of my minor child, to be used in this fashion.

Today's Date / Time

Date

Time

Promotional Code (Optional)