Swim Empowerment Funding Registration 2019

Swim Empowerment Funding Registration Form
Completing the following form is required to confirm funding for your child's swimming lessons and registration at your local YMCA. Please use a separate form for each additional child. Registrations are filled in order of receipt and according to availability at each YMCA.
Name of Parent/Guardian *

First Name Last Name
Name of Child *

First Name Last Name
Phone Number *

Area Code Phone Number
E-mail *
PLEASE ENTER A VALID EMAIL! WE WILL USE THIS TO CONTACT YOU.

Address *

YMCA Branch lessons will be taken at *

Cranston YMCA East Side/Mt. Hope YMCA Kent County YMCA (Warwick) Newman YMCA (Seekonk, MA) South County YMCA (Peace Dale) West Bay Family YMCA (North Kingstown) YMCA Camp Fuller (Wakefield) Newport County YMCA (Middletown) Pawtucket Family Branch YMCA
Swim Lesson start date *

Month Day Year Date Picker Icon
Is the child a member of the YMCA? *

Yes, child is a member No, child is not a member
Age of Child (Must be 5-19 years old) *
How did you hear about Swim Empowerment? *
Let us know how you heard about our swim program. (Be specific!)
Enter the message as it's shown *
Should be Empty:

Swim Empowerment Funding Registration Form