All Can Swim Idaho Online Registration

Registration

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Welcome to AllCanSwim Idaho! I am excited to begin this swim journey with your family. Please complete the following registration form.

**NOW TAKING FDS FUNDS!!!**

This system requires you to enter a valid credit card. If on FDS, it will NOT be charged. There are items at the pool you can purchase (swim diapers, goggles, etc).

In the "Days/Times Preference" section, write in ANY and ALL day/time preferences that work for you (Sun-Sat)

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info (Not Contact #1 or #2)

Do you use Family Direct Funds? *

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

Work #

Cell # *

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Contact #2 First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Please list diagnoses*

Other medical concerns (ear plugs, seizures, etc.) (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Optional)

Primary Doctor

Days/Times Preference 1*

Days/Times Preference 2*

Days/Times Preference 3

Days/Times Preference 4

Days/Times Preference 5

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Please list diagnoses*

Other medical concerns (ear plugs, seizures, etc.) (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Optional)

Primary Doctor

Days/Times Preference 1*

Days/Times Preference 2*

Days/Times Preference 3

Days/Times Preference 4

Days/Times Preference 5

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Please list diagnoses*

Other medical concerns (ear plugs, seizures, etc.) (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Optional)

Primary Doctor

Days/Times Preference 1*

Days/Times Preference 2*

Days/Times Preference 3

Days/Times Preference 4

Days/Times Preference 5

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Please list diagnoses*

Other medical concerns (ear plugs, seizures, etc.) (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Optional)

Primary Doctor

Days/Times Preference 1*

Days/Times Preference 2*

Days/Times Preference 3

Days/Times Preference 4

Days/Times Preference 5

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Please list diagnoses*

Other medical concerns (ear plugs, seizures, etc.) (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Optional)

Primary Doctor

Days/Times Preference 1*

Days/Times Preference 2*

Days/Times Preference 3

Days/Times Preference 4

Days/Times Preference 5

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Account Information

Leave this blank- *note* You must enter a valid credit card. If on FDS, it will NOT be charged

Leave this blank *note*Cards are for private pay and items at the pool (diapers, goggles, caps, etc)

Credit Card

Card Number *

Exp Month *

Exp Year *

Card Nickname

Name as it appears on card *

Address Line 1

Address Line 2

City

State

Zip*

Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

Student #2 (Show-Hide Details)

Additional Info

Student #3 (Show-Hide Details)

Additional Info

Student #4 (Show-Hide Details)

Additional Info

Student #5 (Show-Hide Details)

Additional Info

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Account Information

Credit Card

Required Policies

(Show-Hide Details)