Summer Swim Lessons Registration Form

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Parent's Name* This field is required.
First Name
Last Name
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Parent's Email* This field is required.This is the email address we will send updates, schedules, and Zoom Meeting links to.
example@example.com
3
Parent's Phone Number* This field is required.
Area Code
Phone Number
4
Address* This field is required.We will deliver the supplies to you for your child to this address.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
United States
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Please choose your township.* This field is required.
Lower Pottsgrove
Upper Pottsgrove
West Pottsgrove
6
1st Child* This field is required.Please see the YMCA Skill Continuum on our website to determine your child's level. If you would like to have them tested prior to the start of classes please contact Pam to make those arrangements.
Child's Full Name
Child's Birth date
Skill Level (1-6)
Tuesday Evening
Thursday Evening
Saturday Morning
Doesn't matter
Please choose best day for lesson.
7
2nd ChildPlease see the YMCA Skill Continuum on our website to determine your child's level. If you would like to have them tested prior to the start of classes please contact Pam to make those arrangements
Child's Full Name
Child's Birth date
Skill Level (1-6)
Tuesday Evening
Thursday Evening
Saturday Morning
Doesn't matter
Please choose best day for lesson.
8
3rd ChildPlease see the YMCA Skill Continuum on our website to determine your child's level. If you would like to have them tested prior to the start of classes please contact Pam to make those arrangements
Child's Full Name
Child's Birth date
Skill Level (1-6)
Tuesday Evening
Thursday Evening
Saturday Morning
Doesn't matter
Please choose best day for lesson.
9
4th ChildPlease see the YMCA Skill Continuum on our website to determine your child's level. If you would like to have them tested prior to the start of classes please contact Pam to make those arrangements
Child's Full Name
Child's Birth date
Skill Level (1-6)
Tuesday Evening
Thursday Evening
Saturday Morning
Doesn't matter
Please choose the best day for lesson.
10
Emergency Contacts:* This field is required.
Full Name
Phone Number
Relationship
Full Name
Phone Number
Relationship
11
Medical Information* This field is required.All medical information is kept strictly confidential. It is extremely important that we have all necessary medical information concerning your child. This also includes any learning disabilities.
Family Physician's Name
Physician's Phone Number
Does child(ren) have any allergies?
Does child(ren) have any medical conditions?
Does child(ren) take any medications?
Does child(ren) require accomodations due to health, physical, social, cognitive and/or behavioral needs?
12
Any participant and/or guardian do hereby agree to the following:

1. To assume all risks and responsibilities of possible damage or injury involved through participation in said activity. I understand I am to furnish my own insurance in case of injury. I understand and request permission to participate in the above activity with the full knowledge that the said activity could result in damage or injury top participate.

2. Agree to indemnify and hold harmless the Pottsgrove Recreation Board, iits departments and agents from liability for personal injury or property damage resulting from myparticipation in said activity.

3. Waive the right to dispute all proper charges once he/she/they have registered and/or participated in the PRB program for which this registration form is received.

4. Agree to allow Pottsgrove Recreation Board to use any photos taken at an activity for futue publications.

5. By providing any email address, I agree to receive emails from Pottsgrove Recreation Board. Email will not be shared with any other entities.
13
Anything else we should know?* This field is required.Please note evening classes may begin as early as 4:30pm and run until 7pm. Saturday classes are between 9am and noon. If you have a special request please let us know here. We do our best to accommodate requests. Class times and more information will be sent by email about 1 week prior to the start of the session. Also, mention it here if you wish to have your child tested prior to the start of lessons for best placement.
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Swim LessonsPlease click on the blue + to choose the correct number of children and then add to your bag to check out. Registrations without payment will NOT be accepted. Once you submit this form you will be taken to PayPal to make your payment. If you have any issues with this form please email Pam @ director@pottsgroverec.com
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