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Swimming Lesson Registration

Child’s Name: _____________________________________________________ ~Age: ____________

Address: ____________________________________________________________________________

Parent Name(s): ____________________________________________________________________

Home Phone: ________________________________ Cell/Work: ____________________________

Email Address: ~_____________________________________________________________________

Medical Consideration(s): ____________________________________________________________

Emergency Contact and Phone #: _____________________________________________________

Session(s): __________________________________________________________________________

o Session 1 Dates: July 7th—July 17th,                  10am—12pm or 5:30pm—7:00pm
o Session 2 Dates: July 21st—July 31st,                 10am—12pm or 5:30pm—7:00pm
o Session 3 Dates: August 4th-August 14th,      10am—12pm or 5:30pm—7:00pm

Swimming Level Instruction Time: _____________________________________________

o       10:00am~Level 3                         o       5:30pm  Level 3
o       10:30am~Levels 1 & 4                            o       6:00pm  Levels 1 & 4
o       11:00am~levels 2, 5, & 6                        o       6:30pm  Levels 2, 5, & 6
o       11:30am~3-5 yr old & parent

Please reference the reverse to determine the appropriate level.

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: ______________________________________________________


Level One~
Introduction to water skills. This class is for those children that are ready to be in the pool without a parent or guardian.
Level Two~
Fundamental Aquatic Skills - for those who can fully submerge face, blow bubbles, and do assisted floats.
Level Three~
Stroke Development - for those swimmers who can fully submerge their head, flutter kick on their back and front with arm action, and can float on own.
Level Four~
Stroke Improvement - for those who have coordinated front and back crawls with rotary breathing, know how to butterfly kick and basic butterfly body motion.
Level Five~
Stroke Refinement - for those who have coordinated front crawl, back crawl, breaststroke, butterfly, and elementary back stroke.
Level Six~
Personal water safety/ lifeguard readiness/ fitness swimmer – a combination of the activities that you can do in the water after you have become a proficient swimmer.
Swimming Lesson Fees (per child):       

Cost per session
Two Sessions
Three Sessions
With a pool pass
Without a pool pass

Please note that lessons are held Monday through Thursday, and that Friday will serve as a make-up day if needed due to severe and /or unsafe weather conditions during scheduled classes. Please check the town website and facebook page for these updates.

check #: ______________ date:______________ amount:______________

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