Registration Form

Parent's Information
First Name --      Last Name--  

Cell Phone No --   Email Address --

Children's Information - (children information is mandatory. There will be delay in registration process if children information is not filled out accurately.) Also once you fill out child's information, you can click the button below "Add Child" you will need to repeat this for as many children as you need to register) 
Child's Name   BirthDate (mm/dd/yyyy)

Previous swim experience with Ms. Emma-  

Has your children Seen a Medical Specialist or had any non-routine, health or behavioral issues, please explain? *
Please include any allergies, medications, surgeries, therapies, hospitalization etc...


  You must click this button for all children even if you only have one child.

You are enrolling the following children -: click here to delete children start again.

Cost of Registration is $65 for 1st year. $30 for 2nd year and free from 3rd year and onwards.

Photo/Video Release:
I give permission to Swim and Survival Academy and its instructors to photograph and record and to utilize photographs or other likenesses of me and/or my minor child(ren) on videotape, audiotape, photograph or any other medium in all forms of advertising, trade and any other lawful purposes including but not limited to: print advertising, photographs, video, website, and social media. I further consent to the use of my name, voice and/or biographical data in connection with such use.

Release of Liability: I release and hold harmless Swim and Survival Academy its owners, operators and instructors from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participants and/or the undersigned, while in or upon the premises or any premises under the control and superivision of Swim and SurvivalAcademy, its owners, operators, pool hosts, or in route to or from any of said premises. I also acknowledge that enrollment, participation in or completion of lessons in no way implies that the participants are drown proof or water safe and that as the parent or legal guardian of the participants, I am ultimately responsible for my child's safety in or around water and must at all times ensure appropriate, vigilant and persistent supervision. *

Assumption of Risk: I understand, agree and acknowledge that there are risks inherent in sports activities conducted by Swim and SurvivalAcademy and its instructors. These activities may be of a hazardous nature and/or may include swimming, diving and a variety of strenuous exercise and physical activities. With the full understanding of the facts, I state that to the best of my knowledge, the participants I am registering have no medical, physical, or emotional conditions that would hinder or prevent safe participation in Swim and Survival Academy programs. *

Enrollment Review and Payment Policies: I understand that I am enrolling for swim lessons with Swim and Survival Academy and that the information submitted on this enrollment form will require review as it is the intent of Swim and Survival Academy to provide each participant with an individualized, effective and safe learning experience. I acknowledge that in some health-related cases, Swim and Survival Academy may not be able to provide services. I certify that all medical/health information I have provided is correct and true and agree to provide additional information, including a physician's clearance if requested, prior to the beginning of any lessons. I understand that in order to secure my child(ren)'s selected lesson time(s) I must pay all applicable registration fees per the instructions sent to me. I understand that participant enrollment may be canceled if payment is not received. *


 This button will only be clickable once you have clicked "Add Child" button above regardless of how many children you are registering. For each child you should fill out information in child section and click "Add child" button . After you successfully register, you will be directed to a Thank You page with confirmation. If you do not get to the Thank You page, you have not successfully registered.