Swimmer's Name
*
First Name
Last Name
Gender
Female
Male
Date of Birth
*
-
Month
-
Day
Year
Date
Country of Birth
Mother's Name
First Name
Last Name
Father's Name
First Name
Last Name
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Swimming Dates (please select all six weeks if your child is completing the full camp at a cost of $750). Also, please note the price for four weeks is $500 and $650 for six weeks
*
I certify that I/my child/ward is physically fit and has been informed by a physician that I/they can participate in the BWSC Swimming Program.
*
Yes
No
I certify that my child/ward has the following medical condition:
Epilepsy
Asthma
None
Other
Email
example@example.com
Signature
Submit
Submit
Should be Empty: