Full Circle Swim Registration

Type of Registration- NEW or RETURNING

Student Name*

First NameMiddle InitialLast Name

Birth Date*

MonthDayYear

Gender*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Responsible Party/Main Contact Name:*

First NameLast Name

Main Contact E-mail:*

example@example.com

Main Contact Number:*

Format: (000) 000-0000.

Alternate Phone Number

Format: (000) 000-0000.

Relationship to Student:*

Occupation

Optional Contact 2 Name:

First NameLast Name

Contact 2 E-mail:

example@example.com

Main Contact Number:

Format: (000) 000-0000.

Relationship to Student:

Do you have a pool in your backyard? *

If no, do you have access to a pool at a close relative's home?

Prior Swim Experience: *

Has your child ever had a traumatic water experience: *

If yes, please explain:

Primary Care Physician:*

Has this student ever seen a medical specialist other than his/her primary care physician?*

If Yes, please explain. If medical clearance is necessary, a copy will need to be provided and please call to discuss, if you have not already done so.

Did your child crawl on hands & knees before walking?*

Referred by:

Is there anything specific that you would like me to know about your child?

POLICIES-

ASSUMPTION OF RISK:

I understand, agree and acknowledge that there are risks inherent in sports activities such as swim lessons conducted by Jordan Johnson. These activities may be hazardous in nature and/or may include swimming, diving and a variety of strenuous exercise and physical activities. With the full understanding of the facts, I state that to the best of my knowledge, the participants I am registering have no medical, physical, or emotional conditions which would hinder or prevent safe participation in swimming lessons.

I have read the Assumption of Risk and agree:*

RELEASE OF LIABILITY:

I release and hold harmless Jordan Johnson, Swim Instructor DBA "Full Circle Swim School, LLC" aka "Swim With Jordan", from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage or injury, including illness &/or death, that may be sustained by the participants and/or the undersigned, while in or upon the premises or any premises under the control and supervision of Jordan Johnson, or in route to or from any of said premises. I also acknowledge that enrollment, participation in or completion of lessons in no way implies that the participants are drown-proof or water safe and that as the parent or legal guardian of the participants, I am ultimately responsible for my child’s safety in or around water and must at all times ensure appropriate, vigilant and persistent supervision.

I have read the Release of Liability and agree:*

FLOTATION DEVICE RISKS & POLICY:

By enrolling my child(ren) in lessons, I understand that the use of any flotation device (water wings, puddle jumpers, swimmies/floaties or even a life jacket) is strongly discouraged. I understand that such devices teach children a head up/feet down posture in the water, known as the "drowning position" and are not conducive to proper swimming. I understand that these devices may give my child(ren) a false sense of security in the water which places them at a much higher risk of accidental drowning. I understand that if my child(ren) are unable to progress through lessons, due to the use of floatation devices in other situations, they will be taken off the schedule & released from swim lessons until we can commit to proper practice. I agree to participate in lessons when asked & do my best to practice properly outside of lessons.
NOTE: *USCG approved life vests must be worn by all children age 6 & under on a moving vessel, however, they are not intended to be used as a "swimming aid" in pools.

I have read the Flotation Device Risks & Policy and agree:*

SOCIAL MEDIA POLICY:

Documenting your child's experiences is important. However, before taking any video or photos, please let me know. Just as you would not appreciate unexpectedly being videoed or photographed, please extend the courtesy of a heads up. Thank You

Social media can shape public opinion of swim lessons. It is best to share videos once your child has reached a certain level of skill. Please consider this when posting videos, photos and/or content regarding your children’s lessons.

Always consider others’ privacy and do not upload, post or forward any content, photo or video that includes a third party unless you have that third party's consent. (i.e. another parent or student in the pool or in the background).

I understand and agree to adhere to these social media policies:*

INCLEMENT WEATHER POLICY:

In the event of bad weather, specifically lightning & thunder- you will be sent a text to cancel lessons asap. I do not cancel for dark clouds or sprinkles.

Please consider I may still be in the pool as you are on your way. I will not answer texts asking if lessons are canceled any sooner than 30 min before your scheduled lesson time. Example, if you are scheduled at 12 noon, please don't text me to ask, "are there still lessons?" if it is raining at 8am. The weather changes quickly, the goal is to not cancel. Consistency is crucial for lesson success.

All lessons missed due to weather will be made up at a later date. No discounts or refunds.

I have read the Inclement Weather Policy. I understand and agree:*

DAILY PROCEDURES & HEALTH POLICY:

Please be on the deck & have your child ready to get in the pool at your scheduled time. Do not enter the pool deck more than 5 min before your scheduled time. Do not arrive too early & park & wait out front, this causes parking issues for others. I cannot stress this enough, please simply be on time- not early! Please exit the pool area as soon as possible after your child’s lesson is over.

All children who are not fully potty trained MUST be in a reusable SWIM diaper, with elastic leg holes. Infants & young children should layer a disposable SWIM diaper under this, in case of bowel movement.
Please have older children use the restroom at home before coming.

Do not apply sunscreen to your child, it makes them slippery in the water & causes chemical problems.

Please have the same parent/guardian bring the child to lessons everyday, if possible. If someone else must bring your child, please make sure they understand these policies & procedures.

If your child is sick, please contact me as soon as possible to cancel. All students must be fever, diarrhea, and vomit-free for 24 hours, unmedicated- before returning to lessons. Allergies & runny nose is usually fine. Please do not bring your child to lessons after vaccinations, same day.
I understand that I am enrolling for swim lessons with Jordan Johnson and that the information submitted on this enrollment form will require review as it is the intent of Jordan Johnson to provide each participant with an individualized, effective and safe learning experience. I acknowledge that in some health-related cases, Jordan Johnson may not be able to provide services. I certify that all medical/health information I have provided is correct and true and agree to provide additional information, including a physician's clearance if requested, prior to the beginning of any lessons.

I have read & understand the daily procedures & health policy:*

ENROLLMENT REVIEW & PAYMENT POLICIES:

There is a one-time, non refundable $50 registration fee for all new students. To hold your lesson time, please send $50 per each NEW student you are registering.
Send via Zelle: 321-271-0036
Send via PayPal: paypal.me/jordanjohnson321
Please send me a screenshot of your payment.

Weekly lesson tuition is $80. Cash payment is preferred. Please bring your payment to lessons on the first day of each week, secure in an envelope & place in the drop box located by the screen door when you walk in. If you would like to make weekly payments electronically, please arrange with me in advance.

All missed lessons will be made up at a later date or credited toward future lessons, at my discretion. No discounts or refunds.

All lessons due to sickness or weather will be made up at a later date, no discounts or refunds. Weekly tuition will be pro-rated if I have to take a day off.

I understand that in order to secure my child(ren)'s selected lesson time(s) I must pay all applicable registration and enrollment fees. I understand that enrollment may be canceled and scheduled lesson times may be released to another participant if payment is not received each week.

I have read the Enrollment Review and Payment Policies and agree:*

Are you registering another student? *

If registering a new or returning student, please continue below.

Student Name

First NameMiddle InitialLast Name

Birth Date

MonthDayYear

Gender

Relationship to Student:

Prior Swim Experience:

Has your child ever had a traumatic water experience:

If yes, please explain:

Primary Care Physician:

Has this student ever seen a medical specialist other than his/her primary care physician?

If Yes, please explain. If medical clearance is necessary, a copy will need to be provided and please call to discuss, if you have not already done so.

Did your child crawl on hands & knees before walking?

Is there anything specific that you would like me to know about your child?

Student Registration Form

Weekly Tuition

Student 2 Registration