Splash Water Safety Online Registration

Registration

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Summer Swim Lesson Registration Now Open!

Welcome to Splash Water Safety where your swimming and safety is our business. Please complete the following registration form and payment to reserve your spot in class. For more information about classes, visit our Services page. Swim lessons are near the bottom of the page.

* 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*

Home or Primary Phone*

Additional Info

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

Health Insurance Carrier

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

Confirm Portal Account Password

Who is your employer?

Employer

Employer Phone

Employer Notes

Contact #2

Contact #2 First Name*

Last Name*

How can we contact you?

Home Phone

Work #

Cell # *

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* (format=mm/dd/yyyy)

Additional Info

School*

Grade Level*

Disabilites*

Special Needs*

Allergies*

Medications*

Primary Doctor

Is Student Up to Date with Immunizations?*

Is Student Beginner, Intermediate, or Advanced?*

Prev. Swim Experience/Skills*

Comfortable in Water? *

Goals*

Anything Else We Need to Know*

Comments

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

School*

Grade Level*

Disabilites*

Special Needs*

Allergies*

Medications*

Primary Doctor

Is Student Up to Date with Immunizations?*

Is Student Beginner, Intermediate, or Advanced?*

Prev. Swim Experience/Skills*

Comfortable in Water? *

Goals*

Anything Else We Need to Know*

Comments

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

School*

Grade Level*

Disabilites*

Special Needs*

Allergies*

Medications*

Primary Doctor

Is Student Up to Date with Immunizations?*

Is Student Beginner, Intermediate, or Advanced?*

Prev. Swim Experience/Skills*

Comfortable in Water? *

Goals*

Anything Else We Need to Know*

Comments

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

School*

Grade Level*

Disabilites*

Special Needs*

Allergies*

Medications*

Primary Doctor

Is Student Up to Date with Immunizations?*

Is Student Beginner, Intermediate, or Advanced?*

Prev. Swim Experience/Skills*

Comfortable in Water? *

Goals*

Anything Else We Need to Know*

Comments

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

School*

Grade Level*

Disabilites*

Special Needs*

Allergies*

Medications*

Primary Doctor

Is Student Up to Date with Immunizations?*

Is Student Beginner, Intermediate, or Advanced?*

Prev. Swim Experience/Skills*

Comfortable in Water? *

Goals*

Anything Else We Need to Know*

Comments

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

Assumption of Risk

I understand, agree, and acknowledge that there are risks inherent in sports activities conducted by Splash Water Safety and Sara Beth Gilbert, including but not limited to paralyzing injuries, brain injuries, and death. These activities may be of a hazardous nature and/or may include activities such as swimming, diving, a variety of strenuous exercise, and physical activities. With the full understanding of the facts, I state that to the best of my knowledge, the student listed has no medical, physical, or emotional health conditions which would hinder or prevent his/her participation in Splash Water Safety's programs. If a condition is present, I am providing the necessary doctor's permission and/or my own permission as parent/guardian of the student to proceed with swim lessons or other activities conducted by Splash Water Safety and Sara Beth Gilbert.