Beginner Swim Lesson Registration

Beginner Swim Lesson Registration

June 9 - July 7, 2025 • Monday - Friday
2025 MEMBERSHIP RENEWAL REQUIRED

To register for swim lessons, all girls must have a current Girls, Inc. annual membership. If needed, you can complete membership registration here. All services and any outstanding balances must be paid in full before the transportation start date.
Student Information
Student Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age*
Birthdate*

MonthDayYear
Date
School
Grade *
Please list any medical history (allergies, learning disabilities, etc.) that we should be aware of in working with this child.
Medical History
Primary Guardian Information
Primary Guardian's Name*

First NameLast Name
Primary Guardian's Relationship*
Primary Guardian's Phone Number*
Please enter a valid phone number.
Primary Guardian's Email*
example@example.com
Primary Guardian's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Guardian's Employer
Primary Guardian's Employer Phone
Additional Emergency Contact

Other than guardian(s) listed above
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Emergency Contact Relationship
Waiver & Liability Release

PLEASE READ CAREFULLY BEFORE SIGNING. THIS IS A RELEASE OF LIABILITY & WAIVER OF CERTAIN LEGAL RIGHTS.
Consent for Emergency Medical Treatment
Registration & Payment
Desired Lesson Dates & Times*
Parent/Guardian Signature*

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Date Signed*

MonthDayYear
Date
Pay Now*
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Swim Lesson Registration Fee
$50.00

Total

$0.00
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Beginner Swim Lesson Registration

Student Information

Primary Guardian Information

Additional Emergency Contact

Waiver & Liability Release

Consent for Emergency Medical Treatment

Registration & Payment