Swim Lesson Registration

Splash Rite Swim School Registration Form
Annual $25 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	Country

E-mail *
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 Wednesday Saturday
FIRST CHOICE Please Select Preferred Time *

8:00 am 8:30 am 9:00 am 9:30 am 10:00 am (Saturday Only) 5:30 pm (not available on Saturday) 6:00 pm (not available on Saturday) 6:30 pm (not available on Saturday)
SECOND CHOICE Please Select Preferred Day *

Monday Wednesday Saturday
SECOND CHOICE Please Select Preferred Time *

8:00 am 8:30 am 9:00 am 9:30 am 10:00 am (Saturday Only) 5:30 pm (not available on Saturday) 6:00 pm (not available on Saturday) 6:30 pm (not available on Saturday)
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 *
We occasionally take pictures of students in action swimming

or doing other activities, for our social media page.

We use these to keep parents and the community

up to date on our wonderful activities, programs, and events.
Please click yes if you WILL give permission to have photographs of your child taken *

Yes No
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
Signature please type *

First Name Last Name
We look forward to splashing with you soon!
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Splash Rite Swim School Registration Form

We look forward to splashing with you soon!