Charlotte Country Day Online Registration

Registration

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Welcome to Charlotte Country Day Swim Lessons! **Please note what session you are signing up for and the cost. Summer/Fall/Spring sessions- MONTHLY cost. Holiday and winter mini sessions (Mid November through January) is by class. If you don't see the class you are looking for, please email aquatics@charlottecountryday.org with your request. **For CCDS Families- note we are unable to transport children to/from extended day.

* 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 or #2)*

Health Insurance Carrier

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

School*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Immunization Notes

ID#

**Please note what session you are signing up for and the cost. Please note what session you are signing up for and the cost. Summer/Fall/Spring sessions- MONTHLY cost. Holiday and winter mini sessions (Mid november through January) is by class.

When completing the registration form, your ID # is your teacher/ staff/ student id #.

Be sure if you are faculty/ staff to enter your ID number and be sure to enter in the comment section you are faculty/ staff, as well.

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Immunization Notes

ID#

When completing the registration form, your ID # is your teacher/ staff/ student id #.

Be sure if you are faculty/ staff to enter your ID number and be sure to enter in the comment section you are faculty/ staff, as well.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Immunization Notes

ID#

When completing the registration form, your ID # is your teacher/ staff/ student id #.

Be sure if you are faculty/ staff to enter your ID number and be sure to enter in the comment section you are faculty/ staff, as well.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Immunization Notes

ID#

When completing the registration form, your ID # is your teacher/ staff/ student id #.

Be sure if you are faculty/ staff to enter your ID number and be sure to enter in the comment section you are faculty/ staff, as well.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Immunization Notes

ID#

When completing the registration form, your ID # is your teacher/ staff/ student id #.

Be sure if you are faculty/ staff to enter your ID number and be sure to enter in the comment section you are faculty/ staff, as well.

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?

Additional Info

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)