Y Semi-Private Swim Registration

I am a:*

YMCA Member
Non-Member

Member Registration Options*

3 Lessons ($100.00)
5 Lessons ($150.00)
7 Lessons ($215.00)
9 Lesson ($280.00)

Non Member Registration Options*

3 Lessons ($120.00)
5 Lessons ($180.00)
7 Lessons ($265.00)
9 Lessons ($330.00)

Today's Date*

Student #1

Student's Name*

Email*

Phone Number*

Address*

Parent's Name*

Student #2

Student's Name*

Email*

Phone Number*

Address*

Parent's Name*

Running Total

$0.00

Total

$0.00

Billing Information

Name*

Credit Card*

Visa
Mastercard
American Express
Discover

Address*

Email*

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