Town of Breckenridge
Lesson Request
* Required
Primary Contact Information
First Name
*
Parent first name
Last Name
*
Parent last name
Primary Phone Number
*
Phone number
Secondary Phone Number
Email
*
Email
Preferred Contact Method
Primary (Text)
Primary (Call)
Email
Secondary (Text)
Secondary (Call)
Participant Information
First Name
*
First name
Last Name
Last name
Gender
*
Sex
M
F
Age
*
Age
Skill Level
*
Skill level
Preschool Beginner
Preschool Advanced
Youth Level 1
Youth Level 2
Youth Level 3
Youth Level 4
Youth Level 5
Youth Level - Swim Team/ Stoke Refinement
Adult Beginner
Adult Intermediate
Adult Advanced/ Athlete Stroke Refinement
Unknown - Please describe ability in the notes section.
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Preferences
Location
Breckenridge Recreation
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
*
Package
1 Private Lesson $40
3 Private Lessons $115
5 Private Lessons $180
1 Semi Private Lesson $55
3 Semi Private Lessons $155
5 Semi Private Lessons $245
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