Swimplify Student Registration

Student Registration 2023
Parent/Guardian Info
Name*

First NameLast Name
e-mail*
Primary Phone*

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact (If Parent/Guardian cannot be reached)*
Relationship to Student*
Emergency Phone*

Area CodePhone Number
Please note: Parent/Guardian listed above assumes primary responsibility for account maintenance.
Student Info
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age
Is the student able to stand or float comfortably in a pool of 4ft-5ft?*

YesNo
What are your weekday and time preferences? (*Class Type Refers to Private, Semi-Private, and Specialized Lessons)*
Add Student 2?

Add Student 2
Student 2 Info
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age*
Is the student able to stand or float comfortably in a pool of 4ft-5ft?*

YesNo
What are your weekday and time preferences? (*Class Type Refers to Private, Semi-Private, and Specialized Lessons)*
Add Student 3?

Add Student 3
Student 3 Info
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age*
Is the student able to stand or float comfortably in a pool of 4ft-5ft?*

YesNew Student
What are your weekday and time preferences? (*Class Type Refers to Private, Semi-Private, and Specialized Lessons)*
We will make any necessary corrections and bill your account. Payment and a current account is required to secure a place in each class. Class sizes limited.
Notes:
Terms and Conditions
Today's Date

MonthDayYear
Date
By checking 'I Agree' below and submitting this form, you, the Parent or Guardian of the above student(s), agree to release "Swimplify LLC", including instructors and assistants from liability for any and all injuries which may occur while training, practicing, performing, or during any water-related event or activity. You also agree that you are responsible for health and accident insurance and any medical costs incurred due to injury. You give permission for emergency medical transportation and treatment of your student(s) at your expense should the need arise. You also give your permission for the public display of any images that your child may appear in.
I Agree
Should be Empty:

Student Registration 2023

Parent/Guardian Info

Student Info

Student 2 Info

Student 3 Info

Terms and Conditions