Swimming Lessons Registration Form Student InformationHow many students do you want to register?* One Two Three Student #1Type of lesson requested*Public Group ($6 per lesson)Private ($21 per lesson)Semi-Private ($13 per student)Student #1 Name* First Last Date of Birth* MM slash DD slash YYYY Skill Level*1 – Beginner2 – Comfortable3 – Basic Strokes4 – Strokes 25 Yards5 – Stroke Refinement6 – AdvancedParent / ChildDay/time Requested*Monday / Wednesday – 5-7pmTuesday / Thursday – 5-7pmSaturday – 9-11amEmergency Contact Person* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email* Student #2Type of lesson requested*Public Group ($6 per lesson)Private ($21 per lesson)Semi-Private ($13 per student)Student #2 Name* First Last Date of Birth* MM slash DD slash YYYY Skill Level*1 – Beginner2 – Comfortable3 – Basic Strokes4 – Strokes 25 Yards5 – Stroke Refinement6 – AdvancedParent / ChildDay/time Requested*Monday / Wednesday – 5-7pmTuesday / Thursday – 5-7pmSaturday – 9-11amDoes this student have the same emergency contact info as above?* Yes No Emergency Contact Person* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email* Student #3Type of lesson requested*Public Group ($6 per lesson)Private ($21 per lesson)Semi-Private ($13 per student)Student #3 Name First Last Date of Birth* MM slash DD slash YYYY Skill Level*1 – Beginner2 – Comfortable3 – Basic Strokes4 – Strokes 25 Yards5 – Stroke Refinement6 – AdvancedParent / ChildDay/time Requested*Monday / Wednesday – 5-7pmTuesday / Thursday – 5-7pmSaturday – 9-11amDoes this student have the same emergency contact info as above?* Yes No Emergency Contact Person* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email* Δ
