First Name
Middle Name
Last Name
Date of Birth
Age
Gender
Address of Property (where service is needed)
City/Suburb
State/Province
Postal/Zip Code
Emergency Contact Name
Emergency Contact Phone
Relationship to Participant
First Name
Last Name
Street Address
City/Suburb
State/Province
Postal/Zip Code
Phone Number
Email Address
Swimming Experience
Beginner
Intermediate
Advanced
None
List any previous swimming lessons or experience.
Preferred Class Level
Parent & Tot
Preschool
Child Beginner
Child Intermediate
Child Advanced
Teen/Adult Beginner
Teen/Adult Intermediate
Teen/Adult Advanced
Preferred Days & Times: (Please list your preferred days and times for classes. We will do our best to accommodate your requests.)
1st Choice
2nd Choice
3rd Choice
Does the participant have any medical conditions, allergies, or disabilities we should be aware of?
If yes, please explain
Is the participant currently taking any medications?
If yes, please list
Photo/Video Release: I grant permission to [Swimming School Name] to use photographs and/or videos of the participant for promotional purposes, including brochures, website, and social media
Liability Waiver: I understand and agree that participation in swimming lessons involves inherent risks. I hereby release [Swimming School Name], its staff, and instructors from any liability for injuries or accidents that may occur during classes. I have read and understand the full waiver (available upon request).
Enter text | Enter text | Fees | Amount | |
|---|---|---|---|---|
Parent & Tot | $100.00 | $0.00 | ||
Preschool | $110.00 | $0.00 | ||
Child Beginner | $120.00 | $0.00 | ||
Child Intermediate | $130.00 | $0.00 | ||
Child Advanced | $140.00 | $0.00 | ||
Teen/Adult Beginner | $150.00 | $0.00 | ||
Teen/Adult Intermediate | $160.00 | $0.00 | ||
Teen/Adult Advanced | $170.00 | $0.00 | ||
SubTotal | $0.00 | |||
Registration Fee | $50.00 | |||
Total | $50.00 |
Payment Method
Online Payment
Check
Cash
Card
Parent/Guardian Signature (if participant is a minor)
Participant Signature (if 18 years or older)
Thank you for registering for swimming classes with us! We look forward to seeing you in the pool!
| Item total | $50.00 |
| Total | $50.00 |