Swimmers by Jessica
Email address *
Child's name: *
Child's date of birth: YEAR/Month/Date *
Parent's name: *
Address: *
Cell phone number: *
Child's previous swimming experience: *
Child's physician's name: *
Physician's phone number: *
Please list any allergies: *
Are vaccines up to date? *
Does your child have any special needs or developmental delays that we need to take into account when determining class sizes? *
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