Dell JCC Aquatics

Lesson Request

Agreement To Charge

By completing the form below, you agree to have the Dell JCC charge the amount for the package selected to the card on file for membership.

Scheduling Notice

Once this form is completed, your card will be charged based on the package selected, and you will receive an email with instructions on how to book the lessons. All lessons expire 6 months from the date this form is received. Private & Semi-Private lesson clients can not be connected with an instructor more than 30 days in advance.

* 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 *

Member Type

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

	AM	AFTN	PM	Morning	Afternoon	Evening
S	Sunday
M	Monday
T	Tuesday
W	Wednesday
R	Thursday
F	Friday
S	Saturday

Packages

Select Available Package