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Community Recreation Center

svankirk@pocatello.us

144 Wilson Avenue, Pocatello, Idaho 83201

208-232-3901

Private Swim Lesson Intake Form

Private swim lessons are available for students ages 3 years and older.

***NOTE (8/1/19): Private swim lessons will not be available until late September 2019, following our annual maintenance closure and transition to Fall staff.***

Parent/Guardian Contact

Parent/Guardian Name

Do you text?

Student

Student Name

Swim Level/Ability (please mark approximate swim ability)

Does the student have any degree of fear of water?

Does the student have any physical or mental conditions that would be helpful to be aware of for instructional modifications?