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 within 72 hours of registration to secure enrollment.
Today's Date

MonthDayYear
Type of lesson? (Please select only one (1) option)

Other
NAACP CODE
Are you interested in becoming a member of the Aurora, NAACP?
Swimmer's Name

First Name Last Name
Swimmer's Gender
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
Do you receive text at this number? Only used for swim school notifications.
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
Do you receive text at this number? Only used for swim school notifications.
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
Current Skill Level (Please choose most accurate response)

Other
What would you like the swim coach to know prior to swim lesson(s).
1ST CHOICE - 2nd AURORA, CO, NAACP SWIM CAMP EVENING SCHEDULE 2026

Other
CHECK ALL THAT APPLY FOR CHOICE(S) - 2nd AURORA, CO, NAACP SWIM CAMP EVENING SCHEDULE 2026

Other
MEN ONLY GROUP LESSON - FIRST CHOICE - TIME (Please Select One Preferred Time) Starting June 5, 2026 - month-to-month, 30-mintue lesson

Other
Men Start Date

MonthDayYear
Men Alternate Start Date (only if applicable)

MonthDayYear
KID'S GROUP LESSON - FIRST CHOICE - TIME (Please Select One Preferred Time) Starting June 5, 2026 - August 28, 2026 month-to-month, 30-minute lessons

Other
KID'S GROUP LESSON - SECOND CHOICE - TIME (Please Select One Preferred Time) Starting June 5, 2026 - August 28, 2026 month-to-month, 30-minute lessons

Other
Kid's Start Date

MonthDayYear
Kid's Alternate Start Date

MonthDayYear
How did you find us?

Other
If you were referred by a friend please let us know who, so we can thank them!
Do you give permission to have photographs of your child taken?
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
All information provided in this registration form is true and accurate to the best of my knowledge.
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
My Products
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$25 Aurora NAACP Registration Fee$25.00
Non-refundable

Quantity
Item subtotal:$0.00

$50 Splash Rite Registration Fee$50.00
Non-refundable

Quantity

$45 Private Swim Lessons$45.00
30-Minute Private Lesson

Quantity

$25 Group Swim Lessons$25.00
30-Minute Group Lesson

Total $0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty:

Splash Rite Swim School/Splash Rite Foundation

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

Non-refundable registration fee is required within 72 hours of registration to secure enrollment.

We look forward to splashing with you soon!

My Products

Payment Methods