Noah's Ark Swim School Online Registration

Registration

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Welcome to Noah's Ark Swim School! After submitting your registration you will receive a confirmation email. Your class(es) will begin upon registration. If wait listed, we will contact you with the next available spot when it becomes available. Your credit card or bank account will NOT be charged until we have received your registration and applied any applicable sibling or other discounts. Please call us 203-272-7946 or email info@noahsarkswimschool.com with any questions

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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

Contact #1

Contact #1 First Name*

Last Name *

Relation*

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

Who is your employer?

Employer

Employer Phone

Employer Notes

Contact #2

Contact #2 First Name

Last Name

Relation

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Who is your employer?

Employer

Employer Phone

Employer Notes

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student School

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Choose the class(es) you would like to enroll into by clicking the "Search" button below. YOUR CLASS(ES) WILL BEGIN UPON REGISTERING (please disregard dates listed). If wait listed, we will contact you with the next available spot. Your credit card or bank account will NOT be charged until we have received your submitted registration with class enrollment. Enrollment into a wait listed class will not be charged. Please call 203-272-7946 or email info@noahsarkswimschool.com with any question

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student School

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student School

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student School

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student School

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Enroll in Classes

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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

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

Account Number

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)

Who is your employer?

Contact #2

How can we contact you?

Who is your employer?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

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Student #3 (Show-Hide Details)

Additional Info

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Student #4 (Show-Hide Details)

Additional Info

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Student #5 (Show-Hide Details)

Additional Info

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Questions or Concerns

Payment Information

Credit Card

eCheck/Bank Draft

Required Policies

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