Annette's Swim School Online Registration

Registration

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Enrollment for 2025 has begun & space is limited so please register NOW to reserve your spot. Don't wait!

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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*

Health Insurance Carrier

Your Neighborhood's Name*

Swim Lesson Location*

Request a specific instructor

Is your pool heated?*

Permission to use video?

Contact #1

Contact #1 First Name*

Last Name *

Type*

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

Type

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

T-Shirt Size

School*

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Mon-LIST ALL AVAILABLE HOURS*

Tues-LIST ALL AVAILABLE HOURS*

Wed-LIST ALL AVAILABLE HOURS*

Thur/Fri-LIST AVAILABLE HOURS *

Sat/Sun-LIST AVAILABLE HOURS *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

School*

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Mon-LIST ALL AVAILABLE HOURS*

Tues-LIST ALL AVAILABLE HOURS*

Wed-LIST ALL AVAILABLE HOURS*

Thur/Fri-LIST AVAILABLE HOURS *

Sat/Sun-LIST AVAILABLE HOURS *

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

School*

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Mon-LIST ALL AVAILABLE HOURS*

Tues-LIST ALL AVAILABLE HOURS*

Wed-LIST ALL AVAILABLE HOURS*

Thur/Fri-LIST AVAILABLE HOURS *

Sat/Sun-LIST AVAILABLE HOURS *

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

School*

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Mon-LIST ALL AVAILABLE HOURS*

Tues-LIST ALL AVAILABLE HOURS*

Wed-LIST ALL AVAILABLE HOURS*

Thur/Fri-LIST AVAILABLE HOURS *

Sat/Sun-LIST AVAILABLE HOURS *

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

School*

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Mon-LIST ALL AVAILABLE HOURS*

Tues-LIST ALL AVAILABLE HOURS*

Wed-LIST ALL AVAILABLE HOURS*

Thur/Fri-LIST AVAILABLE HOURS *

Sat/Sun-LIST AVAILABLE HOURS *

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)

Who is your employer?

Contact #2

How can we contact you?

Who is your employer?

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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