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REGISTRATION INFORMATION
Family Information
*
Indicates required field
Number of children registering for lessons
*
1
2
3
Family Name
*
Home Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Mother
Name
*
First
Last
Cell Phone
*
Email
*
Father
Father's Name
*
First
Last
Phone Number
*
Email
*
Student Information
1st Child
Name
*
First
Last
Select One
*
New Student
Returning Student- 2nd Year
Returning Student- 3rd Year or more
Gender
*
Female
Male
DOB
*
Age in months
*
Choose Skill Level That Is Most Accurate
*
No Skills- First Time Student
Basic Swimming- Has swimming skills but lacks survival skills
Completed Rollback to Float
Completed Swim Float Swim
Completed Survival Skills & Ready for Stroke
Other
Has your child previously taken Swim Lessons? If yes, what program / when?
*
How comfortable is your child in/around the water?
*
Has your child ever had a NEGATIVE experience with water? If yes, please explain.
*
Has your child used floatation devices? If yes, please explain.
*
Child's Medical History - Please Choose ALL That Apply To Your Child
*
Special Needs / Exceptionalities
CPR
Medical Specialist / ER Physician
Long Term Prescription Medication
Ear Tubes / Frequent infections
Allergies / Epi-pen Needed
Asthma / Chronic Respiratory
Head inJury
Loss Of Consciousness
Seizures
Cardiac Abnormality / Murmur
Learning Disability
Behavior Issues
ADD / ADHD
Sensory Integration Dysfunction
Therapy OT / PT
Fever For More Than 48 Hours
Fever For More Than 5 Days
Chronic Illness
Chronic Diarrhea / Constipation
Bowel / Bladder infections
Gastro-Esophageal Reflux
Continued Complications From Birth
NONE OF THE ABOVE APPLY TO MY CHILD
Does your child have any health concerns or medical conditions not outlined above?
*
Yes
No
Please explain ALL boxes checked
*
Please be as thorough as possible. Include dates & details.
Please explain any other health concerns or medical conditions not outlined above.
*
Is there anything else you would like us to know about your child?
*
Family has/lives near
*
Pool
Pond/Lake/River
Ocean
Hot Tub
Boat
Other
2nd Child - (Scroll Down if complete)
Name
*
First
Last
Select One
*
New Student
Returning Student- 2nd Year
Returning Student- 3rd Year or more
Gender
*
Female
Male
DOB
*
Age in months
*
Choose Skill Level That Is Most Accurate
*
No Skills- First Time Student
Basic Swimming- Has swimming skills but lacks survival skills
Completed Rollback to Float
Completed Swim Float Swim
Completed Survival Skills & Ready for Stroke
Other
Has your child previously taken Swim Lessons? If yes, what program / when?
*
How comfortable is your child in/around the water?
*
Has your child ever had a NEGATIVE experience with water? If yes, please explain.
*
Has your child used floatation devices? If yes, please explain.
*
Child's Medical History - Please Choose ALL That Apply To Your Child
*
Special Needs / Exceptionalities
CPR
Medical Specialist / ER Physician
Long Term Prescription Medication
Ear Tubes / Frequent infections
Allergies / Epi-pen Needed
Asthma / Chronic Respiratory
Head inJury
Loss Of Consciousness
Seizures
Cardiac Abnormality / Murmur
Learning Disability
Behavior Issues
ADD / ADHD
Sensory Integration Dysfunction
Therapy OT / PT
Fever For More Than 48 Hours
Fever For More Than 5 Days
Chronic Illness
Chronic Diarrhea / Constipation
Bowel / Bladder infections
Gastro-Esophageal Reflux
Continued Complications From Birth
NONE OF THE ABOVE APPLY TO MY CHILD
Does your child have any health concerns or medical conditions not outlined above?
*
Yes
No
Please explain ALL boxes checked
*
Please be as thorough as possible. Include dates & details.
Please explain any other health concerns or medical conditions not outlined above.
*
Is there anything else you would like us to know about your child?
*
Family has/lives near
*
Pool
Pond/Lake/River
Ocean
Hot Tub
Boat
Other
Submit
Registration - Step #5
Schedule Lessons
Click here to move on to
Step #4 -
Payment
UA-28270065-1
