Swim Lesson Registration

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
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 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
Alternate Start Date (only if applicable) *

Month Day Year
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!
Should be Empty:

Splash Rite Swim School Registration Form

Annual non-refundable registration fee is required for each swimmer prior to first lesson.

CORONAVIRUS (COVID-19) QUESTIONNAIRE:

We look forward to splashing with you soon!