Registration

Swim Lesson Registration

Parent/Guardian Name(Required)

Employer

Parent/Guardian Email(Required)

Parent/Guardian Phone(Required)

Street Address

City/State

Zip Code

Second Parent/Guardian Name

Employer

Second Parent/Guardian Email

Second Parent/Guardian Phone

Contact if parents are unavailable: relationship/phone #(Required)

Swimmer Information and Medical History

Swimmer’s Full Name	Date of Birth	Actions

There are no Swimmers.

Please click ‘Add Swimmer’ above and complete one form for each swimmer.

Payment

Enter number of swimmers for each Level below

Level 1

Price: $50.00

Level 2

Price: $65.00

Level 3

Price: $50.00

Level 4

Price: $75.00

Payment Option(Required)

Processing Fee

Price: $0.00

Total

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Order Token

We must have a medical form on file for each swimmer before being permitted to participate in lessons.

Swimmer’s Full Name(Required)

Date of Birth(Required)

Please select the swim lesson level and day/time you would like this child to attend.(Required)

Level 1 - Beginner/Mommy & Me ┃ Level 2 - Pre-Swim Team ┃ Level 3 - Intermediate ┃ Level 4 - Advanced Stroke Training (for swim team members)

Doctor’s Name

Address

Phone Number

Health History: Please list all allergies (drug and/or food).

Does your child have any of the following conditions?

Asthma

Ear Infections

Kidney Disease

Diabetes

Orthopedic

Epilepsy

Strep Throat

Neurological

Heart Disease

Please explain any serious or chronic illness:

Known physical, emotional or learning problems:

Any conditions that coaches should be aware of:

Please list all medications taken regularly:

I, the undersigned parent/legal guardian of the above-mentioned participant indicated by the legal signature below, state that said participant is physically able to participate and has my permission to participate in swim lessons at the Poland Swim Club.

Consent to Treat: I give my consent to the Poland Swim & Tennis Team and its representatives to obtain medical care from any licensed physician, hospital, or clinic for the above-mentioned participant for any injury or illness that could arise during participation in Poland Swim lesson activities. I also give permission for ambulance transfer if needed.

Parent/Guardian Signature(Required)

Parent/Guardian Name(Required)

First Last

Relationship to Swimmer

Date

Subtotal

$0.00

Order Token