Skip to form

Community Recreation Center

144 Wilson Avenue, Pocatello, Idaho 83201


Private Swim Lesson Intake Form

PLEASE NOTE: Private swim lessons are available for individual students (private) or pairs of students (semi-private) of equal swimming ability. Students must be 3 years of age or older.

Private Lesson Process

  1. Complete and submit this form.
  2. Once the form is received, you will be assigned a private lesson instructor. (Please allow up to a week for this to occur.)
  3. The assigned instructor will contact you to schedule your day and time.
  4. If at any time you have an issue, please contact Stacie, the Recreation Manager, at 208-234-6233.

Parent/Guardian Contact Information

Parent/Guardian Name

Do you text?

Student Information

How many students will be receiving the swim lesson(s)?

Student Name

Student #1 Name

Student #2 Name

Swim Level/Ability (please mark approximate swim ability)

Is there any degree of fear of the water?

Are there any physical or mental conditions that would be helpful to be aware of for instructional modifications?