L.D. Swim & Safety, Inc. Online Registration

Registration

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Welcome to LD Swim & Safety DBA Loving Dolfin! You have chosen well! Now your swimmer(s) will get the exceptional aquatic training that he/she deserves while being able to have the convenience to learn in your own backyard pool. Just add water and watch your swimmer SHINE! Please complete the following registration form so I can know about you and your swimmers.

* 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*

Contact #1

Contact #1 First Name*

Last Name *

Type*

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

Contact #2

Contact #2 First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Disabilities (Leave blank if N/A)*

Special Needs (Leave blank if N/A)*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Private ? Y/N*

Semi-Private? Y/N*

Pod Squad? Y/N*

Private (1 swimmer)?

Semi-Private (2 swimmers of the same level)?

Pod Squad (3-4 swimmers of the same level)?

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*

Additional Info

Disabilities (Leave blank if N/A)*

Special Needs (Leave blank if N/A)*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Private ? Y/N*

Semi-Private? Y/N*

Pod Squad? Y/N*

Private (1 swimmer)?

Semi-Private (2 swimmers of the same level)?

Pod Squad (3-4 swimmers of the same level)?

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*

Additional Info

Disabilities (Leave blank if N/A)*

Special Needs (Leave blank if N/A)*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Private ? Y/N*

Semi-Private? Y/N*

Pod Squad? Y/N*

Private (1 swimmer)?

Semi-Private (2 swimmers of the same level)?

Pod Squad (3-4 swimmers of the same level)?

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*

Additional Info

Disabilities (Leave blank if N/A)*

Special Needs (Leave blank if N/A)*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Private ? Y/N*

Semi-Private? Y/N*

Pod Squad? Y/N*

Private (1 swimmer)?

Semi-Private (2 swimmers of the same level)?

Pod Squad (3-4 swimmers of the same level)?

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*

Additional Info

Disabilities (Leave blank if N/A)*

Special Needs (Leave blank if N/A)*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Private ? Y/N*

Semi-Private? Y/N*

Pod Squad? Y/N*

Private (1 swimmer)?

Semi-Private (2 swimmers of the same level)?

Pod Squad (3-4 swimmers of the same level)?

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

Enroll in Classes

Select Class *

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?

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

Required Policies

(Show-Hide Details)