Registration FormAqua Squad Swim With Becca

Aqua Squad Swim With Becca
Registration Form

Please fill out the form below and pay the registration fee in order to secure your time slot!
Class Information & Registration Policy
Did you schedule lessons with Becca already and have a start date? If not, please contact her before registering.*

YesNo
Swimmer Information
Student*

First NameLast Name
Date of birth * Must be at least 6 months *

MonthDayYear
Date
Age in months/years*
Choose Skill Level That Fits Best.*
Please Describe All Previous In Water Experience*
Does this child attend daycare/pre-school either full time or part time?*

YesNo
Name of Pre-school/Daycare:*
Child's Favorite Toy or Character
Scheduling Requests/Comment? What Start Date did you and Becca talk about?*
Time*

Hour Minutes

AM/PM Option
Name of Student's Pediatrician or Primary Health Care Physician *
Has This Student Ever Been Seen By A Medical Specialist Other Than His Pediatrician?*
If Yes, Please Explain & Include Date of Last Visit
Does this student have any health issues or concerns such as allergies, current medications, therapy, history of seizures, etc. *
If Yes, Please Explain
Parent/Guardian and Emergency Contact InformationDetails:
Parent Name*

First NameLast Name
Occupation*
Parent Name #2
Occupation #2
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Okay To Text?*

YesNo
E-mail*
example@example.com
How did you hear about us? If referred by a friend or family member, please include their name. If you found us through a website or search engine, please include the name of the site or search engine. Thank you!*
Please Specify*
Will You Be Registering A 2nd Student?*

YesNo
Swim with Becca Liability Waiver & Enrollment Agreement

Please read the following terms carefully. You must check each box to indicate agreement before completing registration.
Release of Liability
I hereby release, waive, discharge, and hold harmless Swim with Becca, its owners, instructors, operators, pool hosts, affiliates, and agents from any and all liability, claims, demands, causes of action, damages, or losses—including but not limited to bodily injury, illness, death, or property damage—arising out of or related to participation in swim lessons, whether on-site at Swim with Becca facilities or during travel to and from such locations.I understand that participation in swim lessons does not imply that a child is "drown-proof" or water-safe. I acknowledge and accept that as the parent or legal guardian, I am solely responsible for my child’s safety in or around water at all times, regardless of participation in lessons.*

I have read the following and agree
Assumption of Risk
I understand and acknowledge that swim instruction involves physical activity and inherent risks, including but not limited to: drowning, slips and falls, impact with pool surfaces, water inhalation, and unforeseen medical events. With full awareness of these risks, I voluntarily assume all risks and responsibility for any harm that may arise from participation.I confirm that to the best of my knowledge, the participant(s) I am registering have no medical, physical, or emotional conditions that would prevent or hinder their safe participation in swim instruction. I agree to inform Swim with Becca of any new or evolving medical conditions immediately and will provide a physician's clearance if requested.*

I have read the following and agree
Media Release
I grant permission to Swim with Becca and its authorized representatives to take photographs, video, or other recordings of me and/or my child(ren) during swim instruction or related activities. I agree that these images or recordings may be used for promotional, educational, and marketing purposes in print, digital, or social media formats, without compensation. All such media will remain the property of Swim with Becca.*

I have read the following and agreeI do not agree
Enrollment & Payment Policies
Survival Lessons are held 3 days a week, for up to 15 minutes per day, over a 6-8 week session.Scheduling is handled by Coach Becca, and once a time is selected, it remains the same for the session.The registration fee must be paid and is non-refundable and valid only for the current season.Weekly tuition is due on time; failure to pay may result in loss of the time slot.Missed lessons or early withdrawal do not excuse tuition for the current week.Lesson credits, if granted, are valid for one calendar year and are non-transferable.*

I have read the following and agree
📝 Registration Fees
Registration fees are required to reserve your time slot and are non-refundable. These fees do not apply toward tuition and must be paid prior to the start of lessons in order to secure placement.

New Students (First-Year Enrollment):
$100 for the first child
$60 for the second child
$50 for the third child
Returning Students (Returning Season):
$35 flat fee per child
(Returning registration is for students previously enrolled in Aqua Squad Swim with Becca. This fee secures your time slot but is not applied toward weekly tuition.)
💵 Weekly Tuition
$150 per child, per week
Tuition is due every Thursday for the upcoming week’s lessons.

Lesson Packages

These 30-minute, one-on-one lessons are designed for swimmers who are ready to continue building skills, confidence, and endurance in the water.

6-Lesson Package
$70 per lesson
Total: $420
12-Lesson Package
$60 per lesson
Total: $720

Late Fee Policy:
A $15 late fee will be applied to accounts not paid on time. Lessons will be postponed until the account is current.

✅ Payment Notes

Please include your child’s name and in the payment note or memo line put Registration(Example: “Ava – Registration ”)All fees must be received in full to guarantee lesson times.
💳 Accepted Payment Methods

You may use any of the following methods to pay registration fees and weekly tuition:

1. Venmo
Username: @Becca-McAmis
(No additional service charge at this time)
2. Zelle
Phone: 315-529-4319
I confirm that I have read, understood, and agree to all the above terms. By checking this box, I acknowledge this serves as my digital signature for the Aqua Squad Swim with Becca waiver and enrollment agreement.*

I agree
Signing your name below constitutes that you are in full agreement to the terms outlines above and submits your electronic signature.**

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Aqua Squad Swim With Becca

Registration Form

Class Information & Registration Policy

Swimmer Information

Swim with Becca Liability Waiver & Enrollment Agreement

Release of Liability

Assumption of Risk

Media Release

Enrollment & Payment Policies

💳 Accepted Payment Methods