The Stephens Family YMCA (Champaign County YMCA)

Lesson Request

Thank You for filling out the private lesson request form. Please allow 24-48 hours for correspondence to confirm your placement on the waiting list. Completion of this form does not guarantee immediate placement with an instructor.

* Required

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 *

REMOVE PARTICIPANT

ADD PARTICIPANT

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 *