Aqua Journeys Swim School Online Registration

Registration

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Thank you for choosing Aqua Journeys Swim School! The skill of swimming is one that you/your child will benefit from for life! **Please understand, a stored credit card is required to register, but it will NOT be charged at this time.** ***You MUST speak with someone on our team about scheduling your child for lessons***

* 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 (Not Contact #1 or #2)

Coupon/Gift Card Code

Contact #1

Contact #1 First Name*

Last Name *

Type

How Can We Contact You?

Home Phone

Cell # *

Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Aqua Journeys Swim School. 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

Who is your employer?

Employer

Employer Phone

Employer Notes

Contact #2

Contact #2 First Name

Last Name

Type

How can we contact you?

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

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*

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

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Transportation

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)*

Primary Doctor*

Immunizations YN

Immunization Notes

Skill Notes

Does this student walk?*

Does this student crawl?*

Preferred class time?*

Photo Consent?*

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

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

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Transportation

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)*

Primary Doctor*

Immunizations YN

Immunization Notes

Skill Notes

Does this student walk?*

Does this student crawl?*

Preferred class time?*

Photo Consent?*

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

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

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Transportation

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)*

Primary Doctor*

Immunizations YN

Immunization Notes

Skill Notes

Does this student walk?*

Does this student crawl?*

Preferred class time?*

Photo Consent?*

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

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

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Transportation

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)*

Primary Doctor*

Immunizations YN

Immunization Notes

Skill Notes

Does this student walk?*

Does this student crawl?*

Preferred class time?*

Photo Consent?*

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

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

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Transportation

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)*

Primary Doctor*

Immunizations YN

Immunization Notes

Skill Notes

Does this student walk?*

Does this student crawl?*

Preferred class time?*

Photo Consent?*

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Please fill out CREDIT CARD Payment Method

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*

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

Account Number

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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)

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

eCheck/Bank Draft

Required Policies

(Show-Hide Details)