Swimming Saves Lives 2016

Swim Lesson Registration

Thank you for registering for free swim lessons. Please complete the registration information below.

A short survey follows this registration for a study we are completing about participants' reasons for taking part in this program. Participation in this study is optional and not required for participation in the free swim lessons.

The first initiative of its kind, focusing solely on adult swimmers, this program was initiated at Simon's Rock two years ago. Volunteers from Simon’s Rock’s adult swim team, the PaceMakers, members of the US Masters Swimming organization, teach lessons to community members throughout the month. This is truly a collaborative enterprise. Our research team's objective is to learn more about your previous and current experiences with swimming so as to better understand those whom this program is intended to serve.

Question Title

* 1. Address

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 2. Indicate your preferred dates and time slots for Sunday lessons.

	4:00	4:35
Sunday, April 3rd.	Sunday, April 3rd. 4:00	Sunday, April 3rd. 4:35
Sunday, April 10th.	Sunday, April 10th. 4:00	Sunday, April 10th. 4:35
Sunday, April 17th.	Sunday, April 17th. 4:00	Sunday, April 17th. 4:35
Sunday, April 24th.	Sunday, April 24th. 4:00	Sunday, April 24th. 4:35

Question Title

* 3. Indicate your preferred dates and time slots for Wednesday lessons.

	5:00	5:35
Wednesday, April 6th.	Wednesday, April 6th. 5:00	Wednesday, April 6th. 5:35
Wednesday, April 13th.	Wednesday, April 13th. 5:00	Wednesday, April 13th. 5:35
Wednesday, April 20th.	Wednesday, April 20th. 5:00	Wednesday, April 20th. 5:35
Wednesday, April 27th.	Wednesday, April 27th. 5:00	Wednesday, April 27th. 5:35

Other (please specify)