Swim Clo Aquatics and Fitness Inc. Online Registration

Registration

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Welcome! You have come to the right place as we teach our students to Swim in 1/4 of the time thanks to our unique Learn-to-Swim Program. Please note the financial investment up front with us may be more than other programs; however, what other programs do in 4 years we do in 1 year, saving you time (the most precious commodity)!

Your registration date is:

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name

Family Information

Family/Account Last Name*

Where do you live?

Home Address*

City*

State/Prov*

Postal Code*

Primary Phone*

Additional Info

Emergency Contact, Relationship to swimmer, Cell & Home Ph, Home Address (Not Contact #1,#2)*

Which location?*

Contact #1

Contact #1 First Name*

Last Name *

Relationship to swimmer/s*

How Can We Contact You?

Work #

Cell # *

Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Swim Clo Aquatics and Fitness Inc.. 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*

Relationship to swimmer/s*

How can we contact you?

Home Phone

Work #

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

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School Grade

Special Needs? If so, are they low, medium, or high functioning? (Leave blank if NONE)

Medical/Learning Concerns (Asthma, Autism etc.)*

Medications*

Swim Level *

Complete this form & ‘submit’. To pay via credit card: we will charge you within 1-3 business days & will apply any credits before charging.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School Grade

Special Needs? If so, are they low, medium, or high functioning? (Leave blank if NONE)

Medical/Learning Concerns (Asthma, Autism etc.)*

Medications*

Swim Level *

Complete this form & ‘submit’. To pay via credit card: we will charge you within 1-3 business days & will apply any credits before charging.

Enroll in Classes

Select Class *

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School Grade

Special Needs? If so, are they low, medium, or high functioning? (Leave blank if NONE)

Medical/Learning Concerns (Asthma, Autism etc.)*

Medications*

Swim Level *

Complete this form & ‘submit’. To pay via credit card: we will charge you within 1-3 business days & will apply any credits before charging.

Enroll in Classes

Select Class *

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School Grade

Special Needs? If so, are they low, medium, or high functioning? (Leave blank if NONE)

Medical/Learning Concerns (Asthma, Autism etc.)*

Medications*

Swim Level *

Complete this form & ‘submit’. To pay via credit card: we will charge you within 1-3 business days & will apply any credits before charging.

Enroll in Classes

Select Class *

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School Grade

Special Needs? If so, are they low, medium, or high functioning? (Leave blank if NONE)

Medical/Learning Concerns (Asthma, Autism etc.)*

Medications*

Swim Level *

Complete this form & ‘submit’. To pay via credit card: we will charge you within 1-3 business days & will apply any credits before charging.

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

Country *

City

State/Prov*

Postal Code*

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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)