Child's Information
First Name:
Last Name:
Age:
Choose one
4
5
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18
Date of Birth:
Month
Choose one
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
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5
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Year
Choose one
2003
2002
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1991
1990
1989
1988
1987
Phone:
Address:
City:
State:
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)
Session One
September 5 - November 14 (No Class October 24)
Session Two
September 7 - November 16 (No Class October 26)
Day: Tuesdays
Day: Thursdays
Choose a time:
4 - 4:30 P.m.
4:30 - 5 p.m.
Choose a time:
4 - 4:30 P.m.
4:30 - 5 p.m.
Skill Level
Choose the appropriate skill level for your child:
(For more information about levels,
click here
)
Level 1
Level 2
Level 3
Level 4
Medical Information
Does your child have any medical concerns?
Yes
No
Please list any and all conditions and cocerns in the box below:
Emergency Contact Information
Mother's Name:
Work Phone:
Home Phone:
Father's Name:
Work Phone:
Home Phone:
Emergency Contact Name & Relationship:
Work Phone:
Home Phone:
Print and Sign
Please print and sign the following form and remit with your payment. Remember you must either mail or bring in your payment to the Civic Center within 5 business days of submitting this form for your registration to be valid.
Swim Lesson Consent and Release Form
Please Note The Following Information
Attention: This registration is
not
a real time registration process. Please indicate below if you would like to be contacted by phone or email to let you know that your registration is complete.
Phone
Email
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Email
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