*Baby Seals Registration and Questionnaire

Baby Seals Swim Academy Registration

Steffi McMillan Ketzler (805) 235-7535

You learned about the program from:
Friend / Referred by:
AdWebPhonebookPhysicianDemo
Other:
Student Information
Student's Name:
Age:
Years:
Months:
D.O.B:
Address:

Address

Street Address Line 2

CityState / Province

Zip
Mother's Name:
Occupation:
Father's Name:
Occupation:
Cell Phone:
Home Phone:
Email:
example@example.com
Are Text Messages Ok?

YesNo
Gender:

MaleFemale
Meds currently taken:
Birth Weight:
Height:
Pregnancy or Delivery problems:
Full term:
Premature:
Weeks premature:
ICU:
Oxygen needed:
Developmental Milestone (Months):
Sit alone:
Crawl:
Stand alone:
Walk:
Name of Pediatrician:
Office Phone Number:
Format: (000) 000-0000.
Please answer the following by checking YES or NO:

If you answer YES, please explain in the space below.
Seen by Medical Specialist:

YESNO
Bowel or Bladder Problems:

YESNO
Surgery:

YESNO
Heart Murmur or Defect:

YESNO
Allergies:

YESNO
Gastro-Esophageal Reflux

YESNO
CPR:

YESNO
Chronic Illness:

YESNO
Head Injury/Loss of Consciousness:

YESNO
Fever Longer than 1 Week:

YESNO
ADD (Learning Disorder):

YESNO
Therapy:

YESNO
Therapy:

OTPTSpeechOther
Seizures:

YESNO
Lactose Intolerance:

YESNO
Asthma:

YESNO
Respiratory Problems:

YESNO
Ear Infections:

YESNO
Ear Tubes:

YESNO
Please explain in detail if any of the above YES questions apply:
Aquatic History
Family has or vacations near any of the following. Check if YES.

PoolHot TubPondLakeCanalBoatOther
Previous Aquatic Instructions, if any:
Program Type:
Where:
When:
Are all family members aquatically skilled? YN

YESNO
Has your child ever had an aquatic accident incident?

YESNO
If YES, please explain:
Has your child ever used a flotation device?

YESNO
Type of Flotation Device:
How long:
I understand the nature of BABY SEALS Swim Academy lessons.

I give my consent for my child to participate in this program, committing my child to the BSSA program.

I have paid the tuition and I am commiting my child to the BSSA program for a minimum of FIVE/EIGHT Weeks of Instructions.

I understand that upon commencement of lessons, the SIX Weeks tuition is non-refundable should I choose to withdraw my child from the program.
Signature
Date

MonthDayYear
Date
Should be Empty:

Baby Seals Swim Academy Registration

Steffi McMillan Ketzler (805) 235-7535

Student Information

Developmental Milestone (Months):

Please answer the following by checking YES or NO:

Aquatic History

Previous Aquatic Instructions, if any: