Learn To Swim Registration Form
Name (last)			(first)			(middle)
Address				City			Zip
Have You had a Recent Change of Address in the last 4 Years?
yes	Previous :
no
Work Number			Home Number			Cell Number
Email Address				Name of Emergency Contact			Phone Number
Child Name (last)			(first)			(middle)
Child Date of Birth			Gender			Any Additional Information
Course Component			Course ID Number		Amount Paid		Course Date/ Time
Level One: Intro to Water Skills
Level Two: Fund of Aquatic Skills
Level Three: Stoke Development
Level Four: Stroke Improvement
Level Five: Stroke Refinement
Level Six Fitness Swimming
Level Six Lifeguarding Readiness
Level Six Personal Water Safety
Parent and Child Aquatics: 3 yrs
Parent and Child Aquatics: 4 yrs
Parent and Child Aquatics: 5yrs
For Adult/ Teen Class put an "A" next to the class					Total Fee
Credit Card Information:
Card Type:		MasterCard		Visa
Card Number					Exp. Date
Name on Card (Print)					Date
Please List the Names of the People who may be allowed to Sign Your Child In and Out.
Name			Relation			Number
Things to Remember:
1) You Must Sign Your Child In and Out of Every Class.
	No Child Will Leave The Pool Without  Being Signed Out
2) A Legal Adult Must Be Prensent During Your Child's Class
3) Your Child May Miss Only Three Classes, not counting rain days
4) Girls Should Wear One Piece Bathingsuits, Boys- Lined Swimtrunks
5) Only Students in Pool Area During Class
	If You are Unable to Sit Up Stairs Please Contact Ben Hughes on the First Day Of Class
6) The Fans Will be Turned On at the Swim Coordinator's Discretion
If You Have Any Questions Please Contact Ben Hughes at 409-882-2332
Check Us Out Online at redcrossorange.org