Open Water Adventures Online Registration

Registration

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Upon completion of the Registration form you will be directed to the Parent Portal where you will make your class selection for the waitlist. We will contact you to confirm enrollment and schedule before your card will be charged. Currently all of our lessons at all levels and schedules are full and only available for waitlisting.

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name

Family Information

Family Account Name Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info*

Preferred Day of the Week?*

Available 9am-1pm Weekdays?*

Available 4pm-5pm Weekdays?*

Available 5pm-8pm Weekdays?*

Available 9:30-1pm Saturdays?*

Contact #1

Primary Contact First Name*

Last Name *

Relationship to Student*

How Can We Contact You?

Cell # *

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Secondary Contact First Name

Last Name

Relationship to Student

How can we contact you?

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Student Email

Any history of head injury or concussion? If yes, please explain:*

Any history of Asthma, wheezing, inhaler use? If yes, please explain:*

Any history of blackouts, fainting, epilepsy, seizures, or convulsions? If yes, please explain:*

Any history of Anxiety, extreme fear, trauma, or PTSD related to water/swimming, noise or crowds?*

Allergies to Food, Medication, Insect stings, environmental, seasonal? *

Medications Used Daily - This information will only be used in the event of a medical emergency.*

Student requires special accommodations for physical or mental disability? If Yes please explain:*

Taken Swim Lessons Before?*

Are they a beginner swimmer?*

What Strokes do they know?*

Can they float on their back?*

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Student Email

Any history of head injury or concussion? If yes, please explain:*

Any history of Asthma, wheezing, inhaler use? If yes, please explain:*

Any history of blackouts, fainting, epilepsy, seizures, or convulsions? If yes, please explain:*

Any history of Anxiety, extreme fear, trauma, or PTSD related to water/swimming, noise or crowds?*

Allergies to Food, Medication, Insect stings, environmental, seasonal? *

Medications Used Daily - This information will only be used in the event of a medical emergency.*

Student requires special accommodations for physical or mental disability? If Yes please explain:*

Taken Swim Lessons Before?*

Are they a beginner swimmer?*

What Strokes do they know?*

Can they float on their back?*

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Student Email

Any history of head injury or concussion? If yes, please explain:*

Any history of Asthma, wheezing, inhaler use? If yes, please explain:*

Any history of blackouts, fainting, epilepsy, seizures, or convulsions? If yes, please explain:*

Any history of Anxiety, extreme fear, trauma, or PTSD related to water/swimming, noise or crowds?*

Allergies to Food, Medication, Insect stings, environmental, seasonal? *

Medications Used Daily - This information will only be used in the event of a medical emergency.*

Student requires special accommodations for physical or mental disability? If Yes please explain:*

Taken Swim Lessons Before?*

Are they a beginner swimmer?*

What Strokes do they know?*

Can they float on their back?*

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Student Email

Any history of head injury or concussion? If yes, please explain:*

Any history of Asthma, wheezing, inhaler use? If yes, please explain:*

Any history of blackouts, fainting, epilepsy, seizures, or convulsions? If yes, please explain:*

Any history of Anxiety, extreme fear, trauma, or PTSD related to water/swimming, noise or crowds?*

Allergies to Food, Medication, Insect stings, environmental, seasonal? *

Medications Used Daily - This information will only be used in the event of a medical emergency.*

Student requires special accommodations for physical or mental disability? If Yes please explain:*

Taken Swim Lessons Before?*

Are they a beginner swimmer?*

What Strokes do they know?*

Can they float on their back?*

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Student Email

Any history of head injury or concussion? If yes, please explain:*

Any history of Asthma, wheezing, inhaler use? If yes, please explain:*

Any history of blackouts, fainting, epilepsy, seizures, or convulsions? If yes, please explain:*

Any history of Anxiety, extreme fear, trauma, or PTSD related to water/swimming, noise or crowds?*

Allergies to Food, Medication, Insect stings, environmental, seasonal? *

Medications Used Daily - This information will only be used in the event of a medical emergency.*

Student requires special accommodations for physical or mental disability? If Yes please explain:*

Taken Swim Lessons Before?*

Are they a beginner swimmer?*

What Strokes do they know?*

Can they float on their back?*

Add Another Student

Required Policies

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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

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