Amt. Paid __________Amt. Due ________

                                                                                                                                                                Cash ___________  CK # ______________

SWIM LESSONS 2006

Registration Form

All Parents/ Guardians of Swim Lesson Students  MUST remain in the building or in front of the building

 

* For ages 3 & up  * 4 / 45 min. sessions  * $65.00

Circle Group and Date:

Groups:              FRY                GUPPY              GOLDFISH  

Dates & Times:

                SATURDAY'S ONLY :

 

                                 May 6, 13, 20, 27      OR      June 3, 10, 17, 24     OR         July 8, 15, 22, 29

                                FRY: 10:50am - 11:35am         GUPPY: 11:40am - 12:25pm                GOLDFISH: 10am - 10:45am

 

                WEEKLY: (choose one week / mornings or afternoons)  

                               June 5 -8        June 12 - 15            June 19 - 22                June 26 - 29            July 10 - 13            July 17 - 20
 

 FRY: 11 am - 11:45am; 5:50pm - 6:35pm      GUPPY: 11:50am-12:35pm; 5 pm-5:45pm      GOLDFISH: 12:45pm - 1:30pm                                                              

 

 

Child's last name ____________________________First name ___________________MI _____

 

Preferred Name ___________________ DOB ______________  Age _____  M / F _____

 

Address ______________________________________________ zip _______________

 

Parents Name _____________________________    Hm # __________________

 

Wk # ________________________________( M / F )   Cell # ________________( M / F )

 

Emergency # __________________________________ email address _______________

 

Medical Release & Information

 

Swimmer's Name(s)                                      Allergies / Medications, Other info.

 

_______________________________ - ________________________________________

 

_______________________________ - ________________________________________

 

_______________________________ - ________________________________________

 

_______________________________ - ________________________________________

 

Insurance Company / Policy Number ___________________ Insurance contact # _________________

 

I, _____________________________ agree to release Youth Swimming, Inc.,  Walton

Waves, Inc. , Youth Athletic Recreation Company, Inc., & Staff, Bluesprings Sports

Ranch & Staff from any responsibilty for property damage, illness, or injury incurred

by my child at Bluesprings. I also agree to allow Youth Swimming Staff, or another

authority to administer First Aide for my child, if necessary. I, the undersigned, will be

responsible for any & all costs of medical attention and/or treatment.

Signed _________________________Date __________________