Jr's Swim School Online Registration

Registration

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Welcome to Jr's Swim School! Please complete the following registration form.

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name

Family Information

Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Ideal swim time frames M-F?*

Is child homeschooled? (Y/N)*

Contact #1

Contact #1 First Name*

Last Name *

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

Minimum number of characters is 5

Confirm Portal Account Password

Minimum number of characters is 5

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Diagnosis?*

Verbal or physical behaviors?*

Verbal/Nonverbal?*

Preferred Activities/Motivator*

Prior Swim Experience?*

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Diagnosis?*

Verbal or physical behaviors?*

Verbal/Nonverbal?*

Preferred Activities/Motivator*

Prior Swim Experience?*

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Diagnosis?*

Verbal or physical behaviors?*

Verbal/Nonverbal?*

Preferred Activities/Motivator*

Prior Swim Experience?*

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Diagnosis?*

Verbal or physical behaviors?*

Verbal/Nonverbal?*

Preferred Activities/Motivator*

Prior Swim Experience?*

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Diagnosis?*

Verbal or physical behaviors?*

Verbal/Nonverbal?*

Preferred Activities/Motivator*

Prior Swim Experience?*

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)

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)