Clinic Registration

2025 Fall Stroke Clinics
Parent Name*

First NameLast Name
Parent Email*
example@example.com
Parent Phone*
Please enter a valid phone number.
Swimmers Name*

First NameLast Name
Swimmers Age*
Choose Your Clinic

Backstroke (Sept. 13)Breaststroke (Sept. 27)Butterfly (Oct. 4)
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Payment Amount*

USDDescription

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

2025 Fall Stroke Clinics