REGISTRATION FORM - WESTERN AQUATIC SWIMMING ACADEMY

1
Are you registering for your child or as an adult (18+)?* This field is required.Child/Adult Registration
I am registering for my child
I am registering for myself (18+)
2
Applicant’s Name* This field is required.
First Name
Last Name
3
Applicant’s Gender* This field is required.
Male
Female
4
Applicant’s Date of Birth* This field is required.
Date
Month
Day
Year
5
Applicant’s Phone Number* This field is required.
Please enter a valid phone number.
6
Applicant’s Place of Birth* This field is required.
7
Applicant’s Address
8
Applicant’s Email* This field is required.
example@example.com
9
Applicant’s Medical conditions (if applicable)* This field is required.
10
Applicant’s Swimming Experience* This field is required.
No swimming experience
Little to no swimming experience
Advanced swimming experience
11
Is he/she a new or returning student?* This field is required.
New student
Returning student
12
Are you a new or returning student?* This field is required.
New student
Returning student
13
Which location would you prefer?* This field is required.West/ East
Shoppes of Maraval (SOM)
Centre of Excellence (COE)
14
Which day would you prefer to have swimming classes?* This field is required.(Shoppes of Maraval ONLY)
15
Which day would you prefer to have swimming classes?* This field is required.(Centre of Excellence ONLY)
16
How did you find out about Western Aquatic Swimming Academy?* This field is required.
Online
Flyer
Referral
Other
17
Mother’s Name (Guardian #1)* This field is required.
First Name
Last Name
18
Mother’s Phone Number* This field is required.
Please enter a valid phone number.
19
Mother’s Email
example@example.com
20
Mother’s Address
21
Father’s Name (Guardian #2)* This field is required.
First Name
Last Name
22
Father’s Phone Number* This field is required.Yh
Please enter a valid phone number.
23
Father’s Email
example@example.com
24
Father’s Address
25
Email
example@example.com
26
Name of Emergency Contact * This field is required.
First Name
Last Name
27
Emergency Contact’s Relationship to Applicant
Mother
Father
Relative
Friend
Other
28
Phone Number of Emergency Contact #1* This field is required.
Please enter a valid phone number.
29
Phone Number of Emergency Contact #2* This field is required.
Please enter a valid phone number.
30
* This field is required.There will be no swimming lessons on Public holidays. Replacement classes cannot be provided for classes missed during our enrollment with this swim school. Proper swimwear ( spandex ) is required for classes; swim caps for swimmers with long hair and arm bands for children 2 1/2 years - 7 years without swimming experience. Payment via cash/ Linx is accepted at the start of your first class.
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