New Jersey Swim Schools, Inc. Online Registration

Registration

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Thanks for making Njswim your choice for quality swim lessons. Please complete the registration form in its entirety. Once we receive your information, we will reach out to you to set up a time for a swim skills evaluation. Credit cards will not be billed until your class is confirmed. See you at the pool!

* 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

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

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

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Special Needs*

How we can help your child be successful at Njswim? Learning style or strategies at home etc*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Photo Release (Y/N)*

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Special Needs*

How we can help your child be successful at Njswim? Learning style or strategies at home etc*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Photo Release (Y/N)*

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Special Needs*

How we can help your child be successful at Njswim? Learning style or strategies at home etc*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Photo Release (Y/N)*

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Special Needs*

How we can help your child be successful at Njswim? Learning style or strategies at home etc*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Photo Release (Y/N)*

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Special Needs*

How we can help your child be successful at Njswim? Learning style or strategies at home etc*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Photo Release (Y/N)*

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?

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

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)