Swim Lesson Registration

Splash Rite Swim School Registration Form

Including CORONAVIRUS (COVID-19) Questionnaire
Annual non-refundable registration fee is required for each swimmer prior to first lesson.
Today's Date*

MonthDayYear
Type of lesson?*

Baby's Day OutPrivate LessonSemi-PrivateGroup LessonOther
Swimmer's Name*

First Name Last Name
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*
Your social media platforms:
Instagram:@enter here
Facebook: enter here
Other social media platforms:
Other: enter here
Other: enter here
Primary Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Do you receive text at this number? Only used for notifications, ie inclement weather*

YesNo
Swimmer's Name*

First Name Last Name
Swimmer's Birthday*
Any medical history (allergies, learning disabilities, etc.) that we should be aware of while working with child*
Current skill Level*

Has never been in a poolHas been in a poolNot comfortable in the waterIs comfortable in the waterCan put face in waterCannot put face in waterCannot swimBeginner swimmer (any stroke)Skilled swimmer (any stroke)Swim team swimmerOther
Swimmer's Gender*

MaleFemale
Swimmer's Age*
FIRST CHOICE Please Select Preferred Day*

MondayTuesdayWednesdayThursdaySaturdayOther
FIRST CHOICE Please Select Preferred Time*

8:00 am8:30 am9:00 am9:30 am10:00 am10:30 am (seasonal)4:00 pm (not available on Saturday)4:30 pm (not available on Saturday)5:00 pm (not available on Saturday)5:30 pm (not available on Saturday)6:00 pm (not available on Saturday)6:30 pm (not available on Saturday) (seasonal)Other
SECOND CHOICE Please Select Preferred Day*

MondayTuesdayWednesdayThursdaySaturdayOther
SECOND CHOICE Please Select Preferred Time*

8:00 am8:30 am9:00 am9:30 am10:00 am10:30 am (Seasonal)4:00 pm (not available on Saturday)4:30 pm (not available on Saturday)5:00 pm (not available on Saturday)5:30 pm (not available on Saturday)6:00 pm (not available on Saturday)6:30 pm (not available on Saturday) (seasonal)Other
Start Date*

MonthDayYear
Alternate Start Date (only if applicable)*

MonthDayYear
In Case of Emergency (Provide information that is different than previous information.)*

First NameLast Name
Emergency Phone Number*

Area CodePhone Number
Relationship to Student*
Please click yes if you WILL give permission to have photographs of your child taken*

YesNo
Optional: Elaborate on pictures taken.
How did you find us?

FlyerGoogle/Other search engineFacebookFriendPalm Valley Community CenterOther
If you were referred by a friend please let us know who, so we can thank them!
Are you a member of Palm Valley Community Center?*

YesNo
Has any member of your household received a COVID -19 test?*

YesNo
CORONAVIRUS (COVID-19) QUESTIONNAIRE:
If "Yes" please briefly explain.
Has any member of your household tested positive for COVID-19?*

YesNo
If yes, has the family member received a negative test result since the last positive test result?*

YesNo
If "Yes" please briefly explain.
Has any members of your household received any COVID-19 vaccination(s)?*

YesNo
If "Yes" please briefly explain.
Do you agree to temperature check symptom screening for all class participants prior to each 2022 lesson?*

YesNo
All information provided in this registration form is true and accurate to the best of my knowledge.*

TrueFalse
Preparer's name*

First NameLast Name
Signature*

Clear
We look forward to splashing with you soon!

Follow us: IG @pangsbooks and @splashrite.net
Should be Empty:

Splash Rite Swim School Registration Form

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

CORONAVIRUS (COVID-19) QUESTIONNAIRE:

We look forward to splashing with you soon!