Penguin City Swim Online Registration

Registration

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Welcome! Start here to to access our schedule and choose a class. Please note: Our platform requires a credit card on file to gain access to the Parent Portal. You will not be billed until you have selected a class and submitted payment. Call 917-909-7946 or email us at penguincityswim@gmail.com for sign-up support.

* 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)*

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

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*

Student Gender*

Birth Date*

Additional Info

Name of School that your child attends (Adults please write N/A)*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Name of School that your child attends (Adults please write N/A)*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Name of School that your child attends (Adults please write N/A)*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Name of School that your child attends (Adults please write N/A)*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Name of School that your child attends (Adults please write N/A)*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

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)