Registration
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Welcome to Waterbabies Swim School online registration! Please provide your information below and click "Submit" when done. Credit cards are NOT Charged at this time.
How did you hear about us? *   Referral Name:         * - denotes required fields
Family Information:
Family Name:
Contact #1 First Name:* Last Name: * Type:*
Home Phone: Cell #: Work #:
Email:* (Emails are kept confidential)
 
Employer:
Employer Phone:
Employer Notes:
 
Contact #2 First Name: Last Name: Type:
Home Phone: Cell #: Work #:
Email: (Emails are kept confidential)
 
Employer:
Employer Phone:
Employer Notes:
 
Home Address: *
City: * State: * Zip: *
Home Phone: *
Emergency Contact Info:
(Not Contact #1, Contact #2)
Health Insurance Carrier:
 

Student #1 Information:
Student's First Name: * Last Name: *
Student Gender:  Birth Date: * (format=mm/dd/yy)  
School: Grade Level:
Disabilites:
Special Needs:
Allergies:
Medications:
Primary Doctor:
Choose any filter to begin searching for additional classes.

Classes (max 15)
Select Class #1: _______________   
Select Class #2: _______________   
Select Class #3: _______________   
Select Class #4: _______________   
Select Class #5: _______________   

Student #2 Information:
Show-Hide Details
Student's First Name: Last Name:
Student Gender:  Birth Date: * (format=mm/dd/yy) 
School: Grade Level:
Disabilites:
Special Needs:
Allergies:
Medications:
Primary Doctor:

Classes (max 15)
Select Class #1: * _______________   
Select Class #2: _______________   
Select Class #3: _______________   
Select Class #4: _______________   
Select Class #5: _______________   

Student #3 Information:
Show/Hide Details
Student's First Name: Last Name:
Student Gender:  Birth Date: * (format=mm/dd/yy) 
School: Grade Level:
Disabilites:
Special Needs:
Allergies:
Medications:
Primary Doctor:

Classes (max 15)
Select Class #1: * _______________   
Select Class #2: _______________   
Select Class #3: _______________   
Select Class #4: _______________   
Select Class #5: _______________   

Student #4 Information:
Show/Hide Details
Student's First Name: Last Name:
Student Gender:  Birth Date: * (format=mm/dd/yy) 
School: Grade Level:
Disabilites:
Special Needs:
Allergies:
Medications:
Primary Doctor:

Classes (max 15)
Select Class #1: * _______________   
Select Class #2: _______________   
Select Class #3: _______________   
Select Class #4: _______________   
Select Class #5: _______________   

Student #5 Information:
Show/Hide Details
Student's First Name: Last Name:
Student Gender:  Birth Date: * (format=mm/dd/yy) 
School: Grade Level:
Disabilites:
Special Needs:
Allergies:
Medications:
Primary Doctor:

Classes (max 15)
Select Class #1: * _______________   
Select Class #2: _______________   
Select Class #3: _______________   
Select Class #4: _______________   
Select Class #5: _______________   
 
Enter your Full Name: *   
 
 
Comments:  

Credit Card Verification:
   
Name as it appears on card: *  
Card Type: *   Card Number: *  
Card Expiration Month: *   Exp Year: *  
 
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