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SuperStar Aquatics Registration
Child's Last Name *
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Child's First Name *
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Gender *
Age *
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DOB *
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Address *
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City, State and Zip *
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Email Address *
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Mother's Name *
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Occupation *
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Phone #1 *
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Father's Name *
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Occupation *
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Phone #2 *
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Medications currently taking: *
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Check the following if it is accurate for your child *
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Do you live near or have any of these? Check if any apply. *
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Previous aquatic instruction? *
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Has your child ever had an aquatic incident/accident? *
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I understand the nature of SSA lessons. I give my consent for my child,______________________________________(name) to participate in this program. I have paid a non-refundable registration fee and I am committing my child to the SSA program for a minimum of six weeks of instruction. I understand that upon commencement of lessons, the six weeks’ tuition is non-refundable should I choose to withdraw my child from the program. I also agree that any pictures or videos taken of my child while in SSA lessons, may be used for future SSA promotions. *
Child's Name:
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Date *
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Referred by: *
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Parent/Guardian Signature: *
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