swim to me registration form
Full Name (Parent/Adult)
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
Referred By?
How many students do you want to register today?
Register Student #1
Name
*
First Name
Last Name
Age?
*
Previous Student?
*
Yes
No
Any Previous Swimming Experience?
*
Yes
No
Additional Detail on Swim Experience
*
If Yes to previous swimming experience, please describe in detail how they swim. For example, do they require floaties? Do they use goggles? Do they swim on their own? What level of depth do they swim at?
Special Needs?
*
Yes
No
If Yes to Special Needs, please describe:
Register Student #2
Name
*
First Name
Last Name
Age?
*
Previous Student?
*
Yes
No
Any Previous Swimming Experience?
*
Yes
No
Additional Detail on Swim Experience
*
If Yes to previous swimming experience, please describe in detail how they swim. For example, do they require floaties? Do they use goggles? Do they swim on their own? What level of depth do they swim at?
Special Needs?
*
Yes
No
If Yes to Special Needs, please describe:
Register Student #3
Name
*
First Name
Last Name
Age?
*
Previous Student?
*
Yes
No
Any Previous Swimming Experience?
*
Yes
No
Additional Detail on Swim Experience
*
If Yes to previous swimming experience, please describe in detail how they swim. For example, do they require floaties? Do they use goggles? Do they swim on their own? What level of depth do they swim at?
Special Needs?
*
Yes
No
If Yes to Special Needs, please describe:
Register Student #4
Name
*
First Name
Last Name
Age?
*
Previous Student?
*
Yes
No
Any Previous Swimming Experience?
*
Yes
No
Additional Detail on Swim Experience
*
If Yes to previous swimming experience, please describe in detail how they swim. For example, do they require floaties? Do they use goggles? Do they swim on their own? What level of depth do they swim at?
Special Needs?
*
Yes
No
If Yes to Special Needs, please describe:
Register Student #5
Name
*
First Name
Last Name
Age?
*
Previous Student?
*
Yes
No
Any Previous Swimming Experience?
*
Yes
No
Additional Detail on Swim Experience
*
If Yes to previous swimming experience, please describe in detail how they swim. For example, do they require floaties? Do they use goggles? Do they swim on their own? What level of depth do they swim at?
Special Needs?
*
Yes
No
If Yes to Special Needs, please describe:
Register Student #6
Name
*
First Name
Last Name
Age?
*
Previous Student?
*
Yes
No
Any Previous Swimming Experience?
*
Yes
No
Additional Detail on Swim Experience
*
If Yes to previous swimming experience, please describe in detail how they swim. For example, do they require floaties? Do they use goggles? Do they swim on their own? What level of depth do they swim at?
Special Needs?
*
Yes
No
If Yes to Special Needs, please describe:
Register Student #7
Name
*
First Name
Last Name
Age?
*
Previous Student?
*
Yes
No
Any Previous Swimming Experience?
*
Yes
No
Additional Detail on Swim Experience
*
If Yes to previous swimming experience, please describe in detail how they swim. For example, do they require floaties? Do they use goggles? Do they swim on their own? What level of depth do they swim at?
Special Needs?
*
Yes
No
If Yes to Special Needs, please describe:
Submit
Should be Empty: