Swim School Call Back/Interest List Form

Which booking period are you interested in?*
- I'd like a phone call back now please.
- Term 1, Jan-Mar
- Term 2, Apr-Jun
- Term 3, Jul-Sept
- Term 4, Oct-Dec
- None
Which school holiday intensives period are you interested in?*
- I'd like a phone call back now please.
- Jan Holiday Intensives
- Mar/April Holiday Intensives
- June/July Holiday Intensives
- Sept/Oct Holiday Intensives
- None
Which pool would you like to swim at?*
- Mont Albert only
- Ringwood only
- I could swim at either Mont Albert or Ringwood
Student #1:
Name*
First Last
Date of Birth*

DD
MM
YYYY
Swim Level (if known)
Preferred Days/Times
Student #2:
Name
First Last
Date of Birth

DD
MM
YYYY
Swim Level (if known)
Preferred Days/Times
Student #3:
Name
First Last
Date of Birth

DD
MM
YYYY
Swim Level (if known)
Preferred Days/Times
Contact Person:
Name*
First Last
Preferred Phone Number*
Secondary Phone Number
Email*
Enter Email Confirm Email
Extra Comments:
Is there anything else you would like us to know about these students? (eg. Have they done other swimming classes before? Are there any special needs? etc.)
How did you first hear about Healthways Swim School?*

Student #1: