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 an individual student age 3 years 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

Parent/Guardian Name

Do you text?


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?