Splash Rite Registration Form

Splash Rite Swim School/Splash Rite Foundation

REGISTRATION FORM
Non-refundable registration fee is required for each swimmer prior to first lesson.
Today's Date*

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

Baby's Day OutPrivate LessonGroup LessonSemi-Private LessonAurora NAACP Swim CampOther
Are you interested in becoming a member of the Aurora, NAACP?*

YesNo
Aurora NAACP Promo Code
For Aurora NAACP Camp Only
(Aurora NAACP Female Only) Swim Suit Size? While supplies last

SMLXLXXLOther
(Aurora NAACP Male Only) Swim Trunk Size? While supplies last

SMLXLXXLOther
Swimmer's Name*

First Name Last Name
Swimmer's Gender*

MaleFemale
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*
Primary Phone Number*

Area CodePhone Number
Do you receive text at this number? Only used for swim school notifications.*

YesNo
Alternate Phone Number (Please provide a different number than the primary Phone #)

Area CodePhone Number
Do you receive text at this number? Only used for swim school notifications.*

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

Area CodePhone Number
Emergency Contact (Provide information that is different than previous information.)*

First NameLast Name
Emergency Contact Relationship to Student*
Swimmer's Race/Ethnicity (USA Swimming reports)*
Any medical history (allergies, learning disabilities, special need, etc.) the swim coach needs to know while teaching*
Current Skill Level (Please choose most accurate response)*

Has never been in poolHas been in pool, but not comfortable in waterFew to no swimming skills but comfortable in the waterBeginner swimmer (any stroke)Skilled swimmer (any stroke)Swim team swimmerOther
What would you like the swim coach to know prior to swim lesson(s). *
ONE GROUP CAMP EVERY FRIDAY ON JUNE 6, 13, 20, 27, 2025, (30 Min. Class)*

FridayOther
FIRST CHOICE (Please Select Preferred Time)*

3:30 pm4:00 pm4:30 pm5:00 pm5:30 pm6:00 pm6:30 pmOther
SECOND CHOICE (Please Select Preferred Time)*

3:30 pm4:00 pm4:30 pm5:00 pm5:30 pm6:00 pm6:30 pmOther
Start Date*

MonthDayYear
Alternate Start Date (only if applicable)

MonthDayYear
Do you give permission to have photographs of your child taken?*

YesNo
Optional: Elaborate on pictures taken.
How did you find us?*

Aurora NAACPFacebookFlyerFriendGoogle/Other search engineInstagramOther
If you were referred by a friend please let us know who, so we can thank them!
Your social media platforms:
Instagram:@enter here
Facebook: enter here
Other social media platforms:
Other: enter here
Other: enter here
All information provided in this registration form is true and accurate to the best of my knowledge.*

TrueFalse
Preparer's name*

First NameLast Name
Signature*

Clear
We look forward to splashing with you soon!

Follow us: IG @pangsbooks and @splashriteswim FB: Lotta D Todd
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Splash Rite Swim School/Splash Rite Foundation

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

We look forward to splashing with you soon!