Midwest Aquatics Swim and Scuba Online Registration

Registration

Already a customer? Click here to login.

Welcome to the Midwest Aquatics registration form. If you have filled out this form previously, please don't do so again. All you need to do is log in to your existing account and agree to our updated policies by clicking here.
If you have any questions about this registration form, please give us a call at (913) 402-0403.

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name*

Family Information

Family Last Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info*

Cell CARRIER for texts*

Data rates may apply for text

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone *

Work #

Cell #

Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Midwest Aquatics Swim and Scuba. Standard message and data rates apply. Reply STOP to opt out

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 # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Midwest Aquatics Swim and Scuba. Standard message and data rates apply. Reply STOP to opt out

Email (Emails are kept confidential)

Disabilities (Leave blank if NONE)

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?

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

Credit Card

Required Policies

(Show-Hide Details)