Swim Haven Learner Registration Form
Fill out the form carefully for registration
Student Name
First Name
Middle Name
Last Name
Birth Date
Please select a month
January
February
March
April
May
June
July
August
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October
November
December
Month
Please select a day
1
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Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
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2015
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2012
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1929
1928
1927
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1925
1924
1923
1922
1921
1920
Year
Gender
Please Select
Male
Female
N/A
Parent or Guardian Name
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Correspondence E-mail
example@example.com
Billing E-mail (if different)
example@example.com
Mobile Number
Emergency Number
Work Number
Course Selection
Please Select
Baby Classes (3 weeks - 18 months)
Learn To Swim (18 months an up)
Disabilities (contact us to discuss)
Any previous swimming experience?
Does the learner suffer from any medical condition?
Does the learner have any learning or physical disabilities?
Preferred day and time for lessons? (We can't guarantee this)
Additional comments
Signature
*
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