Online Registration Child’s name(Required) First Date of birth(Required) MM slash DD slash YYYY Age Male / Female(Required) Street address Street Address City ZIP / Postal Code Mother’s Name First Occupation Father’s Name First Occupation Email CellADD/ADHD Asthma Chronic condition Ear infections Ear tubes Heart murmur/defect Premature birth weeks Seizures Reflux Other: Water Experience: (Is your child around any of the following at home, family members, friends, or on vacation?) Pool Lake/Pond River/Canal Ocean Boat Previous swimming lessons? Program type Where Has your child ever had an accident involving water?(Required) Yes No Does your child have a fear of water?(Required) Yes No Does your child use a flotation device?(Required) Yes No Type of device How long? How did you hear about this program? Day Care Facebook Flyer Web search Pediatrician Friend Other Registration is not complete until this form is signed and returned. The participant and participant’s family hold Little Swimmers of Georgia, LLC, and any employees or volunteers harmless of any and all liability. I fully understand and release the entities of any and all liability. I hereby authorize any medical treatment necessary while attending lessons. Parent SignatureDate MM slash DD slash YYYY I understand that this is a Survival Swimming Program. I give my consent for my child to enroll in Little Swimmers of Georgia, LLC survival swimming program. I also agree that any pictures or videos taken of my child during lessons are the sole property of Little Swimmers of Georgia, LLC, and may be used for future Little Swimmers of Georgia, LLC promotions. By signing this form, I understand that there is a one-time, $50 non-refundable registration fee to secure my time slot and that there are no refunds for any unused lessons for any reason. Parent SignatureDate MM slash DD slash YYYY Download Physical Form
