Splash Rite Registration Form

Splash Rite Swim School/Splash Rite Foundation

REGISTRATION FORM
Follow us: FB: @Lotta D Todd, IG: @splashriteswim, and IG: @pangsbooks,
$50 Non-refundable registration fee is required.
Today's Date

MonthDayYear
Type of lesson? (Please select only one (1) option)

Other
Are you interested in becoming a member of the Aurora, NAACP?
Swimmer's Name

First Name Last Name
Swimmer's Gender
Swimmer's Birthday
Swimmer's Age
Parent/Guardian's Name (if applicable)

First NameLast Name
Relationship to Student
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail Address (Lesson confirmation is sent to this email)
Primary Phone Number

Area CodePhone Number
Do you receive text at this number? Only used for swim school notifications.
Alternate Phone Number (Please provide a different number than the primary phone #)

Area CodePhone Number
Emergency Phone Number (Please provide a different number than primary phone #s.)

Area CodePhone Number
Do you receive text at this number? Only used for swim school notifications.
Emergency Contact (Please provide information that is different than previous information.)

First NameLast Name
Emergency Contact's Relationship to Student
Swimmer's Race/Ethnicity (USA Swimming reports)
Please list any mental or medical history (allergies, learning disabilities, special need, etc.)
What would you like the swim coach to know prior to swim lesson(s).
Current Skill Level (Please choose most accurate response)

Other
1ST CHOICE - Day of the Week

Other
1ST CHOICE - Start Date
1ST CHOICE - Class Time
2ND CHOICE - Day of the Week

Other
1ST CHOICE - Start Date
2ND CHOICE - Class Time
How did you find us?

Other
Do you give permission to have photographs of your child taken?
Optional: Elaborate on pictures taken.
Your social media platforms:
Instagram: @enter here
Facebook: enter here
Other social media platforms:
Other: enter here
Other: enter here
If you were referred by a friend, please let us know who, so we can thank them!
All information provided in this registration form is true and accurate to the best of my knowledge.
Preparer's name

First NameLast Name
Signature
We look forward to splashing with you soon!

Stay connected: FB: Lotta D. Todd, IG: @splashriteswim and @pangsbooks
SWIM LESSON PAYMENTS PROCESSING
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$50 Splash Rite Registration Fee$50.00
Non-refundable

Quantity

$45 Private Swim Lessons$45.00
30-Minute Private Lesson

Quantity

$25 Group Swim Lessons$25.00
30-Minute Group Lesson

Quantity

Total $0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty:

Splash Rite Swim School/Splash Rite Foundation

Follow us: FB: @Lotta D Todd, IG: @splashriteswim, and IG: @pangsbooks,

$50 Non-refundable registration fee is required.

We look forward to splashing with you soon!

SWIM LESSON PAYMENTS PROCESSING*

Payment Methods

SWIM LESSON PAYMENTS PROCESSING