Father's Name
First Name
Last Name
Father's Contact Number
(###)
###
####
Mother's Name
First Name
Last Name
Mother's Contact Number
(###)
###
####
Email Address
*
Home Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone Number
(###)
###
####
Today's Date
*
MM
DD
YYYY
Has your child had swim lessons previously?
*
If yes, where?
Prior Swim Experience
Please tell us about your child's previous swim lesson experience. If your child has had swim lessons, where?
How long has it been since he/she was last in lessons?
Current Skill Level
Tell us about your child's current ability in the water.
How will you support your teacher if your child cries?
Do you have a pool at home?
*
How did you hear about us?
*
Brochure
Resign
Online
Friend
Advertisement
Other
If Other, please specify:
If a friend referred you, please give us their name below. We'd like to thank them.
Name of Student 1
*
First Name
Last Name
Gender
*
Male
Female
Decline to state
Date of Birth
*
MM
DD
YYYY
Age
*
Child's Physician
Does your child have any special needs (physical, emotional, medical, allergies) that we need to be aware of while your child is actively participating in swimming lessons? Please specify. (Please also notify your teacher once booked.)
Name of Student 2
First Name
Last Name
Gender
Male
Female
Decline to state
Date of Birth
MM
DD
YYYY
Age
Child's Physician
Does your child have any special needs (physical, emotional, medical, allergies) that we need to be aware of while your child is actively participating in swimming lessons? Please specify. (Please also notify your teacher once booked.)
Name of Student 3
First Name
Last Name
Gender
Male
Female
Decline to state
Date of Birth
MM
DD
YYYY
Age
Child's Physician
Does your child have any special needs (physical, emotional, medical, allergies) that we need to be aware of while your child is actively participating in swimming lessons? Please specify. (Please also notify your teacher once booked.)
When are you available for lessons?
*
*
*
*
*
*
*
*
*
Additional Comments
