Swim registration

Parent’s Name:

Parent’s Email:

Session:

Time/Age

Parent’s Cell Number:

Child’s Name:

Date Of Birth:

Child’s Previous Swimming Experience:

Please list any allergies:

Are the child’s vaccinations up-to-date?

Does your child have any special needs or developmental delays?

Please explain:

Child’s Physician Name:

Physician Telephone Number:

May we use your child’s photograph for our website and/or social media?

I understand the $100 deposit per session to hold my child’s spot in class is non-refundable.

I understand the balance of $250 is due on the first day of class.

I understand that there will be a $25 per-day late fee for balances not paid on time.

I understand that only classes that are rained out or canceled by Swimmers by Jessica will be made up; no other make-ups.

Please type your first and last name if you affirm this statement. “I have enrolled my child in a swimming program of physical activity offered by Swimmers by Jessica. I hereby affirm that my child is in good physical condition and does not suffer any disability that would prevent or limit his/her participation in the program.”

Please type your first and last name if you affirm this statement. “In consideration of my child’s participation in Swimmers by Jessica, for my child, myself and assigns, I hereby release Swimmers by Jessica and it’s employees and owners from any claims, demands and cause of action arising from my child’s participation in this program.”

Please type in your first & last name if you affirm this statement. “I affirm that I have read and understand all the requirements listed above.”

Thank you! Your submission has been received!

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Swim registration

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