Illinois Valley YMCA

Lesson Request

Lessons may take place in either the Lap Pool or the Therapy Pool. Please allow 3-5 business days to be set up with an instructor. Payment is due at the Front Desk upon arrival for first lesson. Receipt must be given to Instructor. Please let us know of any special request you may have.

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Primary Contact Information

First Name *

Last Name *

Primary Phone Number *

Secondary Phone Number

Email *

Preferred Contact Method

Participant Information

First Name *

Last Name

Gender *

Age *

Skill Level *

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Preferences

Location

Special Accommodations or Requests

Objectives

General Availability

Please mark the times of the day you are generally available for lessons week to week

Packages

Select Available Package *