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 info 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<br/>(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

T-Shirt Size

School*

Grade Level*

Disabilities*

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

T-Shirt Size

School*

Grade Level*

Disabilities*

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

T-Shirt Size

School*

Grade Level*

Disabilities*

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

T-Shirt Size

School*

Grade Level*

Disabilities*

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

T-Shirt Size

School*

Grade Level*

Disabilities*

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