Private Swim Lessons Request

Use this form to request private swim lessons with one of our lifeguard- and CPR-certified swim instructors.

Parent / Guardian Information

Name(Required)

First Middle Last

Gender(Required)

Male

Female

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email Address(Required)

Member?(Required)

Yes

Instructor Requested

It is not guaranteed you will get the instructor you specifically request. Instructors are assigned lessons based on their availability at the time of the request.

Current Swimming Ability of Child(ren) Registering(Required)

Number of Lessons(Required)

Preferred Day(s) of the Week(Required)

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Preferred Time(s)(Required)

8 am

8: 30 am

9 am

9:30 am

10 am

10:30 am

11 am

11:30 am

12 pm

12:30 pm

1 pm

1:30 pm

2 pm

2:30 pm

3 pm

3:30 pm

4 pm

4:30 pm

5 pm

5:30 pm

6 pm

6:30 pm

7 pm

Number of Children You Are Registering(Required)

Child 1 Information

Name(Required)

First Middle Last

Age(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

Member?(Required)

Yes

Child 2 Information

Name(Required)

First Middle Last

Age(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

Member?(Required)

Yes

Child 3 Information

Name(Required)

First Middle Last

Age(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

Member?(Required)

Yes

Child 4 Information

Name(Required)

First Middle Last

Age(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

Member?(Required)

Yes

Child 5 Information

Name(Required)

First Middle Last

Age(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

Member?(Required)

Yes

The undersigned acknowledges and accepts the condition of the service contract that if the client does not show up for a scheduled lesson and has not contacted the instructor of his/her absence 24 hours in advance (barring emergencies), the missed lesson will not be rescheduled.

Fitness Plus Notice of Risk and Release of Liability

Warning: The use of the pool, strength training and other exercise equipment, the track, and use of Fitness Plus generally poses a risk. While some risks may be obvious (weights dropped on bones will cause damage; people drown in swimming pools) some risks are not as obvious. In particular, seemingly healthy people sometimes experience cardiovascular and other health emergencies while exercising and die as a result. It is your responsibility to check with your doctor and make sure you are able to exercise safely, and it is your responsibility to use Fitness Plus in a safe manner.

Having been informed of the risks of using Fitness Plus, I, on behalf of myself, my heirs, and my other successors in interest release Saint Francis Medical Center and its affiliates from all liability or claims arising from my use of the Fitness Plus facility including liabilities and claims based on the negligence or fault of Saint Francis Medical Center (including its Fitness Plus operating division) and its personnel.

I understand it is my responsibility to safeguard my property while I at Fitness Plus.

Parent / Guardian Signature(Required)

My signature below indicates that I have read and understand the foregoing and that I do hereby accept it in its entirety.

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Swim Lessons

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Location and Information

Fitness Plus is located in the Health and Wellness Center on the Saint Francis Medical Center campus at 150 S. Mount Auburn Road in Cape Girardeau, MO. For more information, call 573-331-3355.

Fitness Plus Dexter is located in the Saint Francis Health Center at 1212 Saint Francis Drive in Dexter, MO (by US 60 Outer Road and Harris Drive). For more information, call 573-614-3636.

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