Adult Programs Intake Form | Galter LifeCenter

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Adult Programs Intake Form

Thank you for your interest in private swim lessons at Galter LifeCenter. Please fill out the following form and we will contact you shortly.

Are you a Galter LifeCenter member or nonmember?

Member
Nonmember

First and Last Name

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Date of birth (mm/dd/yyyy)

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Primary Phone Number

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Email Address

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Address

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Zip Code

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Emergency Contact Name

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Emergency Contact Phone Number

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Have you ever had lessons before? If yes, where?

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I am comfortable performing (please select all that apply):

Putting my face in the water
Lateral breathing
Floating on front
Floating on back
Freestyle 25+ yards
Backstroke 25+ yards
Breaststroke 25+ yards
Butterfly 25+ yards

Goals for swimming lessons (please select all that apply):

Learn to swim
Gain comfort in the water
Improve fitness
Swim in open water
Learn competitive strokes
Triathlons
Technique refinement
Overcome fear of swimming
Other

Please specify if you selected "other" in the question above.

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Are there any medical concerns we should be aware of?

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Are you interested in duet lessons?

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How many lessons are you interested in?

3 lessons
6 lessons
12 lessons
Other

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What days are you available?

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

What times are you available?

9 a.m.-noon
Noon-3 p.m.

Please add specific availability information.

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How did you hear about us?

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"I first joined Galter LifeCenter because knees were a problem and the doctor said exercise would be helpful." - Kathleen

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5157 N Francisco Ave.
Chicago, IL 60625
Phone: 773-878-9936
Monday – Thursday: 5 a.m. – 9:30 p.m.
Friday: 5 a.m. – 8 p.m.
Saturday & Sunday: 6:30 a.m. – 6:30 p.m.