New Customer Registration Form

This is a survival swim program that will teach children, depending on their age, to swim-float or swim-float-swim. Children must be walking and no older than 6 years old to be able to complete lessons.

Children will learn to float independently, rest and breath in a float position, and eventually learn the swim-float-swim sequence.
For children to graduate, they must pass a fully clothed checkout at the end of the session.
Lessons will be Monday, Tuesday, Wednesday, and Thursday each week. Each session is 5-6 weeks long.
This session I will be teaching from 3:00pm-5:30pm.
Your child will keep the same time throughout the session.

There will be NO makeup lessons or credits for missed lessons.
Each lesson is a 1:1 lesson that is 10 minutes long.
Cost is $90/week.
Total cost is $450.

A NON-REFUNDABLE deposit of $180 will be due prior to the first lesson. The deposit will cover weeks one and two of lessons.
Weeks three, four, and five will be billed at the beginning of week two.

Parents Name

First NameLast Name

Phone Number

Format: (000) 000-0000.

E-mail

example@example.com

Child’s Full Name

Child’s Age:

Birthdate

Date

Gender

Primary Care Physician Name:

List all medical personnel (PCP, therapist, etc.) child has seen and the purpose of the visit, excluding well check ups:

Has your child had a seizure within the last year?

Child’s experience in water (i.e. wears flotation devices to swim, only walk around where they can touch, is able to have face in to swim independently, no swim experience, or only in water if held by parent):

Questions:

Inquiry Form