Swim4Success Sign-Up
Submission of this form does not guarantee your child a place in our program; placement depends on lesson availability. Please fill out this form once per child you are interested in enrolling; every child must have their own form submitted.
Child Name: LAST, FIRST *
Your answer
Parent Name: LAST, FIRST *
Your answer
Parent Email *
Your answer
Parent Phone Number (write N/A if not applicable) *
Your answer
Child's Date of Birth *
Child's Swim Experience/Level *
Does your child qualify for free or reduced lunch? *
Can you provide proof of Medicaid? *
If no, can you provide proof of another form of health insurance?
Your answer
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