Pricing / Schedule
Specifics
Policies
Waiver
Interest Form
First Name:
Last Name:
E-mail:
Phone:
Address:
City:
State:
--
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
How did you hear about us?
Friend
who?
Web Search
which?
Postcard
where?
Facebook
Media
which?
Advertisement
where?
Other
what?
I am a previous client.
Swimmer(s) Info
This information allows us to recommend the appropriate class times and level.
Child's Name:
Birthdate:
MM
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Swimming & Water Comfort Level:
Fearful
Swims With Flotation Aid
Puts Face In
Swims Without Flotation (Independently)
Will Not Put Face In
Other
Availability
Preferred Class Times:
Please check all that apply.
Sat
Sun
Mon
Tue
Wed
Thu
Fri
Mornings
9:00am - Noon
Mid-day
12:00pm - 3:00pm
Afternoons
3:30pm - 4:30pm
Evenings
5:00pm - 6:00pm
Exceptions / Notes:
(worship, sports, after 1pm on Mondays, school hours, naptimes)
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