Splash Water Safety Registration Form
In order to attend a class offered by Splash Water Safety, you must complete this registration form in its entirety. You understand by completing this form that the instructor
Class Type *
Class Level
See website near bottom if unsure: http://www.splashwatersafety.com/services.html
Location of Pool and/or Classroom *
What location have we agreed upon for these lessons or classes?
Your answer
First and Last Name of Student(s) *
Your answer
Age of Students in Corresponding Order to Above *
If not swim lessons and you are 18+ years of age, please enter Adult.
Your answer
What is Your Completion Goal? (This set of lessons and/or long-term - please specify)
Examples: Safe introduction to water for this set, Make it back to side safely this set, Swim length of the pool long-term, Improve stroke technique this set, Join swim team long-term, etc.
Your answer
Conditions, Medications, Etc. *
If the student has any conditions or takes medication that may affect safety in the water, learning, concentrating, or physical movement, please Select Yes.
Specifics of Conditions, Medications, Etc.
For the safety of the student and instructor, please provide any details that apply to the above question. If the instructor is prepared, it is a safer and more productive environment for everyone. Safety is of the utmost importance, and none of this information is shared unless there is a medical emergency in my presence at which time medical professionals may be apprised of the situation.
Your answer
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