Splash Rite Registration Form

Splash Rite Swim School/Splash Rite Foundation

REGISTRATION FORM
Follow us: FB: @Lotta D Todd, IG: @splashriteswim, and IG: @pangsbooks,
Non-refundable registration fee is required for each swimmer prior to first lesson.
Today's Date*

MonthDayYear
Baby's Day OutPrivate LessonGroup LessonSemi-Private LessonAurora NAACP Swim CampGoodyear Swim CampOther
NAACP CODE
YesNo
Swimmer's Name*

First Name Last Name
MaleFemale
Swimmer's Birthday*
Swimmer's Age*
Parent/Guardian's Name (if applicable)*

First NameLast Name
Relationship to Student*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail Address*
Primary Phone Number*

Area CodePhone Number
YesNo
Alternate Phone Number (Please provide a different number than the primary phone #)*

Area CodePhone Number
Emergency Phone Number (Please provide a different number than primary phone #s.)*

Area CodePhone Number
YesNo
Emergency Contact (Please provide information that is different than previous information.)*

First NameLast Name
Emergency Contact Relationship to Student*
Swimmer's Race/Ethnicity (USA Swimming reports)*
Any medical history (allergies, learning disabilities, special need, etc.) the swim coach needs to know while teaching*
Has never been in poolHas been in pool, but not comfortable in waterFew to no swimming skills but comfortable in the waterBeginner swimmer (any stroke)Skilled swimmer (any stroke)Swim team swimmerOther
What would you like the swim coach to know prior to swim lesson(s). *
Each Swim Camp session includes six (6) private swim lessons. Lessons are 30 minutes in length and are scheduled one per day on Tuesdays, Thursdays, and Saturdays. Please select at least one Swim Camp session, along with your first and second choice for a preferred time slot. All Tuesday, Thursday, and Saturday lessons will be held at the same chosen time each week. Lesson times will be assigned on a first-come, first-served basis.
Camp 1 - April 14th , 16th, 18th, 21st,, 23rd, and 25thCamp 2 - April 28th, 30th, May 2nd, 5th, 7th, and 9thCamp 3 - May 12th, 14th, 16th, 19th, 21st, and 23rdOther
Camp 1 - April 14th , 16th, 18th, 21st,, 23rd, and 25thCamp 2 - April 28th, 30th, May 2nd, 5th, 7th, and 9thCamp 3 - May 12th, 14th, 16th, 19th, 21st, and 23rdOther
Camp 1 - June 2nd, 4th, 6th, 9th, 11th, and 13thCamp 2 - June 16th, 18th, 20th, 23rd, 25th, and 27thCamp 3 - Jun 30th , July 2nd, 7th, 9th, and 11thCamp 4 - July 14th, 16th , 18th, 21st, 23rd, and 25th,July 4th make-up lesson will be on July 28th.Other
Camp 1 - June 2nd, 4th, 6th, 9th, 11th, and 13thCamp 2 - June 16th, 18th, 20th, 23rd, 25th, and 27thCamp 3 - Jun 30th , July 2nd, 7th, 9th, and 11thCamp 4 - July 14th, 16th , 18th, 21st, 23rd, and 25th,July 4th make-up lesson will be on July 28th.Other
Tuesday and Thursday 4:00 pmTuesday and Thursday 4:30 pmTuesday and Thursday 5:00 pmTuesday and Thursday 5:30 pmTuesday and Thursday 6:00 pmTuesday and Thursday 6:30 pmSaturday 8:00 amSaturday 8:30 amSaturday 9:00 amSaturday 9:30 amSaturday 10 amSaturday 10:30 amSaturday 11:00 amSaturday 11:30 amOther
Tuesday and Thursday 4:00 pmTuesday and Thursday 4:30 pmTuesday and Thursday 5:00 pmTuesday and Thursday 5:30 pmTuesday and Thursday 6:00 pmTuesday and Thursday 6:30 pmSaturday 8:00 amSaturday 8:30 amSaturday 9:00 amSaturday 9:30 amSaturday 10 amSaturday 10:30 amSaturday 11:00 amSaturday 11:30 amOther
Start Date*

MonthDayYear
Alternate Start Date (only if applicable)

MonthDayYear
Aurora NAACPPalm Valley Community CenterFacebookFlyerFriendGoogle/Other search engineInstagramTikTokOther
If you were referred by a friend please let us know who, so we can thank them!
YesNo
Optional: Elaborate on pictures taken.
Your social media platforms:
Instagram:@enter here
Facebook: enter here
Other social media platforms:
Other: enter here
Other: enter here
TrueFalse
Preparer's name*

First NameLast Name
Signature*
We look forward to splashing with you soon!

Stay connected: FB: Lotta D. Todd, IG: @splashriteswim and @pangsbooks
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Splash Rite Swim School/Splash Rite Foundation

Follow us: FB: @Lotta D Todd, IG: @splashriteswim, and IG: @pangsbooks,

Non-refundable registration fee is required for each swimmer prior to first lesson.

We look forward to splashing with you soon!