[MAILME_TEMPLATE_TEXT] MailMe! Pro Sample Template MON1SEC1BILLDATE##MON1SEC1BILLDATE## MON2SEC1BILLDATE##MON2SEC1BILLDATE## MON3SEC1BILLDATE##MON3SEC1BILLDATE## [MAILME_TEMPLATE_HTML] Swim Lesson Application Form

Swim Lesson Registration


Child's Information
First Name: ##first_name## Last Name: ##last_name## Age: ##age##


Date of Birth: Month: ##month## Day: ##day## Year: ##year## Phone: ##phone##


Address: ##street_address## City: ##city## State: ##state## Zip: ##zip##

Available Class Times:$50 per session
My child would like to attend the following session of Swim Lessons:
(Choose Either Tuesday or Thurdsay and the time you would like)
Day: Tuesdays Day: Thursdays
Choose a time:
##tuesday_time##		 Choose a time:
##thursday_time##
Will a gift certificate be needed? ##gift_certificate##








Skill Level
Choose the appropriate skill level for your child:
##level##



Medical Information
Does your child have any medical concerns? ##medical_yes_no##
Please list any and all conditions and cocerns in the box below:
##medical_conditions##





Emergency Contact Information
Mother's Name:
##mother_name## 		Work Phone:
##mwork_phone## 		Home Phone:
##mhome_phone##
Father's Name:
##father_name## 		Work Phone:
##fwork_phone## 		Home Phone:
##fhome_phone##
Emergency Contact Name & Relationship:
##econtact_name## 		Work Phone:
##ework_phone## 		Home Phone:
##ehome_phone##








Attention Staff
Please contact the participant by the method indicated below to let him/her know that the registration process is complete when payment is received.
##registration_reply##
##email##