Child Information

Number of Children To Request Free Swim Class For*

Child #1

Child's Name*

Child Age*

: Years

Months

Swim Assessment

Please complete the following questionnaire to help us determine the appropriate class. Continue answering the questions until you answer “NO”

	Yes	No
Is your child comfortable in the water without floaties and able to put their face in the water?
Are they able to independently float on their back and roll over?
Are they able to independently swim 30 feet using kicks and rolling over to breath?
Are they able to perform freestyle and Backstroke 30 feet?
Are they able to side breath while swimming freestyle?
Are they able to swim butterfly and breast Stroke in a basic fashion?
They are able to proficiently swim all four strokes?
Are they able to swim all four strokes and are 11 years old or older?

Child's Name*

Child Age*

: Years

Months

Swim Assessment

Please complete the following questionnaire to help us determine the appropriate class. Continue answering the questions until you answer “NO”

	Yes	No
Is your child comfortable in the water without floaties and able to put their face in the water?
Are they able to independently float on their back and roll over?
Are they able to independently swim 30 feet using kicks and rolling over to breath?
Are they able to perform freestyle and Backstroke 30 feet?
Are they able to side breath while swimming freestyle?
Are they able to swim butterfly and breast Stroke in a basic fashion?
They are able to proficiently swim all four strokes?
Are they able to swim all four strokes and are 11 years old or older?