Splash Rite Swim School Registration Form
Including CORONAVIRUS (COVID-19) Questionnaire
Annual non-refundable registration fee is required for each swimmer prior to first lesson.
Today's Date
*
-
Month
-
Day
Year
Date Picker Icon
Type of lesson?
*
Baby's Day Out
Private Lesson
Semi-Private
Group Lesson
Swimmer's Name
*
First Name
Last Name
Parent/Guardian's Name (if applicable)
*
First Name
Last Name
Relationship to Student
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
E-mail
*
Primary Phone Number
*
-
Area Code
Phone Number
Alternate Phone Number
-
Area Code
Phone Number
Do you receive text at this number? Only used for notifications, ie inclement weather
*
Yes
No
Swimmer's Name
*
First Name
Last Name
Swimmer's Birthday
*
Any medical history (allergies, learning disabilities, etc.) that we should be aware of while working with child
*
Current skill Level (please check all that apply)
*
Has never been in a pool
Has been in a pool
Not comfortable in the water
Is comfortable in the water
Can put face in water
Cannot put face in water
Cannot swim
Beginner swimmer (any stroke)
Skilled swimmer (any stroke)
Swim team swimmer
Swimmer's Gender
*
Male
Female
Swimmer's Age
*
FIRST CHOICE Please Select Preferred Day
*
Monday
Tuesday
Wednesday
Thursday
Saturday
FIRST CHOICE Please Select Preferred Time
*
8:00 am
8:30 am
9:00 am
9:30 am
10:00 am
10:30 am (seasonal)
4:00 pm (not available on Saturday)
4:30 pm (not available on Saturday)
5:00 pm (not available on Saturday)
5:30 pm (not available on Saturday)
6:00 pm (not available on Saturday)
6:30 pm (not available on Saturday) (seasonal)
SECOND CHOICE Please Select Preferred Day
*
Monday
Tuesday
Wednesday
Thursday
Saturday
SECOND CHOICE Please Select Preferred Time
*
8:00 am
8:30 am
9:00 am
9:30 am
10:00 am
10:30 am (Seasonal)
4:00 pm (not available on Saturday)
4:30 pm (not available on Saturday)
5:00 pm (not available on Saturday)
5:30 pm (not available on Saturday)
6:00 pm (not available on Saturday)
6:30 pm (not available on Saturday) (seasonal)
Start Date
*
-
Month
-
Day
Year
Date Picker Icon
Alternate Start Date (only if applicable)
*
-
Month
-
Day
Year
Date Picker Icon
In Case of Emergency
*
First Name
Last Name
Emergency Phone Number
*
-
Area Code
Phone Number
Relationship to Student
*
Please click yes if you WILL give permission to have photographs of your child taken
*
Yes
No
Optional: Elaborate on pictures taken.
How did you find us?
Flyer
Google/Other search engine
Facebook
Friend
Palm Valley Community Center
If you were referred by a friend please let us know who, so we can thank them!
Are you a member of Palm Valley Community Center?
*
Yes
No
CORONAVIRUS (COVID-19) QUESTIONNAIRE:
Has any member of your household received a COVID -19 test?
*
Yes
No
If "Yes" please briefly explain.
Has any member of your household tested positive for COVID-19?
*
Yes
No
If yes, has the family member received a negative test result since the last positive test result?
*
Yes
No
If "Yes" please briefly explain.
Has any members of your household received any COVID-19 vaccination(s)?
*
Yes
No
If "Yes" please briefly explain.
Do you agree to temperature check symptom screening for all class participants prior to each 2022 lesson?
*
Yes
No
All information provided in this registration form is true and accurate to the best of my knowledge.
*
True
False
Preparer's name
*
First Name
Last Name
Signature
*
Clear
We look forward to splashing with you soon!
Submit
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