Aqua Essence Swim Academy Online Registration

Registration

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Welcome to Aqua Essence Swim Academy! Please complete the following registration form to get started. We are excited to have you join us! Once you click on "Submit Registration," you will receive an email confirming your registration. Please log in to your new account to enroll in lessons.

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Referral Information

How did you hear about us?*

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

Province*

Postal Code*

Primary Phone*

Additional Info

Emergency Contact Info (Not Contact #1 or #2)*

Contact #1

Contact #1 First Name*

Last Name *

Relationship*

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

Student #1

Student's First Name*

Last Name*

Birth Date*

Additional Info

School*

Learning or Adapted Abilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Additional Info

School*

Learning or Adapted Abilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Additional Info

School*

Learning or Adapted Abilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Additional Info

School*

Learning or Adapted Abilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Additional Info

School*

Learning or Adapted Abilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Please fill out ONE of the following Payment Methods

Credit Card

Card Number

Exp Month

Exp Year

Card Nickname

Name as it appears on card

Address Line 1

Address Line 2

Country

City

Province

Postal Code

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Transit # (5-digits)

Institution ID (3-digits)

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)

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)