Course Registration Form

Swim Haven Learner Registration Form

Fill out the form carefully for registration
Student Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Parent or Guardian Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / 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
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*

Clear
Should be Empty:

Swim Haven Learner Registration Form