Little Flippers Swim, LLC Online Registration

Registration

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Welcome to Little Flippers Swim! Please complete the following registration form.

* 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*

Contact #1

First Name*

Last Name *

Type

How Can We Contact You?

Home Phone

Cell # Receive Text Message Notifications

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

First Name

Last Name

Type

How can we contact you?

Home Phone

Cell # Receive Text Message Notifications

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Gender*

Birth Date*

Additional Info

Please list any special needs that we should be aware of: (LEAVE BLANK IF NONE)

Please list any allergies that we should be aware of: (LEAVE BLANK IF NONE)

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Gender*

Birth Date*

Additional Info

Please list any special needs that we should be aware of: (LEAVE BLANK IF NONE)

Please list any allergies that we should be aware of: (LEAVE BLANK IF NONE)

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Gender*

Birth Date*

Additional Info

Please list any special needs that we should be aware of: (LEAVE BLANK IF NONE)

Please list any allergies that we should be aware of: (LEAVE BLANK IF NONE)

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Gender*

Birth Date*

Additional Info

Please list any special needs that we should be aware of: (LEAVE BLANK IF NONE)

Please list any allergies that we should be aware of: (LEAVE BLANK IF NONE)

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Gender*

Birth Date*

Additional Info

Please list any special needs that we should be aware of: (LEAVE BLANK IF NONE)

Please list any allergies that we should be aware of: (LEAVE BLANK IF NONE)

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

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?

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

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

Required Policies

(Show-Hide Details)