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Name of Swimmer *

First Name

Last Name

Birth Date *

MM

DD

YYYY

Name of Guardian (can use swimmers name if over 18) *

First Name

Last Name

Phone Number of Guardian *

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

Name of person who will be bringing swimmer to pool *

PLEASE NOTE the guardian/adult bringing the swimmer to the lesson is required to stay for the duration of the class. There will be weeks where the adult/guardian will participate in Water Safety Education.

First Name

Last Name

How well would you rate the swimmers level of oral communication (in English)? *

1 Poor

2

3

4

5 Strong / Well Spoken

How well would you rate the families level of oral communication (in English)? *

1 Poor

2

3

4

5 Strong / Well Spoken

Would co-ed classes prevent the student from learning? *

YES

NO

Would an opposite gender instructor prevent the student from learning? *

YES

NO

What gender does the swimmer identify as? *

MALE

FEMALE

OTHER

Phone Number of person making referral *

(###)

###

####