Blue Dolphins Aquatics, LLC Online Registration

Only a minor student's legal guardian or adult student should complete this registration form.

Annual fees will not be invoiced until services are scheduled at which time annual fees are non-refundable.
Fees will not be charged until an invoice is sent.

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name

Family Information

Family (Student) Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Subdivision*

County of residence*

Contact #1

Primary (Communication & Billing) Contact - First Name*

Last Name *

Relationship to student*

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

Secondary Contact (opted-out of mass email by default) - 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*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Email for Lifeguard Students ONLY

May we use this swimmers' photo on BDA website/publications?*

Swim-Related Concerns (leave blank if none)

Special Needs Info for Instructor

Serious allergic reactions

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Email for Lifeguard Students ONLY

May we use this swimmers' photo on BDA website/publications?*

Swim-Related Concerns (leave blank if none)

Special Needs Info for Instructor

Serious allergic reactions

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Email for Lifeguard Students ONLY

May we use this swimmers' photo on BDA website/publications?*

Swim-Related Concerns (leave blank if none)

Special Needs Info for Instructor

Serious allergic reactions

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Email for Lifeguard Students ONLY

May we use this swimmers' photo on BDA website/publications?*

Swim-Related Concerns (leave blank if none)

Special Needs Info for Instructor

Serious allergic reactions

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Email for Lifeguard Students ONLY

May we use this swimmers' photo on BDA website/publications?*

Swim-Related Concerns (leave blank if none)

Special Needs Info for Instructor

Serious allergic reactions

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)