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

Baby's Day OutPrivate LessonGroup LessonSemi-Private LessonAurora NAACP Swim CampGoodyear Swim CampOther
NAACP CODE
Are you interested in becoming a member of the Aurora, NAACP?*

YesNo
Swimmer's Name*

First Name Last Name
Swimmer's Gender*

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
Do you receive text at this number? Only used for swim school notifications.*

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
Do you receive text at this number? Only used for swim school notifications.*

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*
Current Skill Level (Please choose most accurate response)*

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.
1ST CHOICE - GOODYEAR, AZ, PALM VALLEY COMMUNITY CENTER 2 WEEK CAMP SCHEDULE 2026:*

Not applicableCamp 2 - April 28th, 30th, May 2nd, 5th, 7th, and 9thCamp 3 - May 12th, 14th, 16th, 19th, 21st, and 23rdOther
2ND CHOICE - GOODYEAR, AZ, PALM VALLEY COMMUNITY CENTER 2 WEEK CAMP SCHEDULE 2026:*

Not applicableCamp 2 - April 28th, 30th, May 2nd, 5th, 7th, and 9thCamp 3 - May 12th, 14th, 16th, 19th, 21st, and 23rdOther
1ST CHOICE - AURORA, CO, NAACP SWIM CAMP SCHEDULE 2026*

Not applicableCamp 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
2ND CHOICE - AURORA, CO, NAACP SWIM CAMP SCHEDULE 2026*

Not applicableCamp 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
FIRST CHOICE - TIME (Please Select One Preferred Time for Tues. and Thurs., and Sat.)*

Not applicableTuesday 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
SECOND CHOICE - TIME (Please Select One Preferred Time for Tues. and Thurs., and Sat.)*

Not ApplicableTuesday 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
MEN ONLY GROUP LESSON - FIRST CHOICE - TIME (Please Select One Preferred Time) Starting June 5, 2026 - month-to-month, 30-mintue lesson*

Not ApplicableFriday 5:30 PMFriday 6:00 PMOther
MEN ONLY GROUP LESSON - SECOND CHOICE - TIME (Please Select One Preferred Time) Starting June 5, 2026 - month-to-month, 30-minute lesson*

Not ApplicableFriday 5:30 PMFriday 6:00 PMOther
Men Start Date*

MonthDayYear
Men Alternate Start Date (only if applicable)

MonthDayYear
How did you find us?*

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!
Do you give permission to have photographs of your child taken?*

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
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*
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!