Swim Time

(Please Print)

Date:_______________________________

Last Name:______________________________________ First name:____________________________________

Age:______________________________ Birthdate:_______________________________ Sex:________________

Address: (Street)____________________________, (City) ___________________, (State)_____, (Zip)__________

Class:__________________________ Day:___________________ Time:__________________ Cost:__________

List any medical conditions we should know about (allergies, seizures, asthma etc…)

______________________________________________________________________________________________

______________________________________________________________________________________________

Name of parent to notify:____________________________ Phone:________________ Alt. Phone:______________

Address: (Street)____________________________, (City) ____________________, (State)_____, (Zip)__________

(Child #2)

Last Name:______________________________________ First name:____________________________________

Age:______________________________ Birthdate:_______________________________ Sex:________________

Address: (Street)____________________________, (City) ___________________, (State)_____, (Zip)__________

Class:__________________________ Day:___________________ Time:__________________ Cost:__________

List any medical conditions we should know about (allergies, seizures, asthma etc…)

______________________________________________________________________________________________

______________________________________________________________________________________________

Name of parent to notify:____________________________ Phone:________________ Alt. Phone:______________

Address: (Street)____________________________, (City) ____________________, (State)_____, (Zip)__________

There is a $15.00 registration fee per child annually, with a max of $45.00 a family. All children must have an adult present during class times. Lesson prices are first 2 children reg price and 1/2 off for remaining children.