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Tel. # (508) 886-0048

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 15th—July 26th, 10am—12pm or 5:30pm—7:00pm
o Session 2 Dates: July 29th—August 9th, 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: ___________________________________________ Date:_______________________

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
total for both sessions
Rutland residents with a pool pass*
Rutland residents 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 voicemail for these updates.
check #: ______________ date:______________ amount:______________
“This Institution is an equal opportunity provider.  To file a complaint of discrimination
write USDA, Director, Office of Civil Rights, Washington, DC 20250-9410

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