Little Ocean Aquatics - Student Registration Form
STUDENT INFORMATION
Student's Full Name:
*
Date of Birth:
*
Age:
Gender:
Male
Female
Prefer not to say
PARENT / GUARDIAN INFORMATION
Parent/Guardian's Full Name:
*
Relationship to Student:
*
Phone Number:
*
Email Address:
*
Home Address:
City:
State:
ZIP Code:
EMERGENCY CONTACT
Name:
*
Relationship:
*
Phone Number:
*
MEDICAL INFORMATION
Pediatrician's Name:
Pediatrician's Phone Number:
Does your child have any medical conditions?
*
No
Yes (Please explain)
If yes, please explain:
Does your child have any allergies?
*
No
Yes
If yes, please list:
Is your child currently taking any medications?
*
No
Yes
If yes, please list:
Does your child have any physical limitations, developmental concerns, or special needs?
*
No
Yes
Medical Information Continued
Please explain:
Has your child ever had any of the following?
Seizures
Heart Condition
Asthma
Ear Tubes
Autism Spectrum Disorder
ADHD
Other:
Other conditions (if selected 'Other'):
SWIMMING EXPERIENCE
Has your child taken swimming lessons before?
*
Yes
No
If yes, where?
Current swimming ability:
*
No Experience
Comfortable in Water
Can Float with Assistance
Can Float Independently
Swimming Experience Continued
Beginner Swimmer
Intermediate
Advanced
Is your child afraid of the water?
*
Yes
No
PROGRAM SELECTION
*
Swim-Float-Swim Survival Program (20 lesson/ complete)
10 Lesson Package (introduction to swimming)
For ages 5+
Maintenance program
Preferred Start Date:
Preferred Days:
Monday
Tuesday
Wednesday
Thursday
Preferred Time:
PHOTO & VIDEO RELEASE
I authorize Little Ocean Aquatics to photograph and/or record my child during lessons for educational and promotional purposes, including social media, printed materials, and the company website.
*
Yes
No
LIABILITY WAIVER
I understand that participation in swimming lessons involves inherent risks. I voluntarily allow my child to participate in programs offered by Little Ocean Aquatics. I agree to release and hold harmless Little Ocean Aquatics, its owners, instructors, and staff from any claims, injuries, or damages arising from participation in swimming lessons, except in cases of gross negligence or willful misconduct. I certify that all information provided on this form is true and accurate to the best of my knowledge.
PARENT/GUARDIAN AGREEMENT
I have read and understand the information provided above.
Parent/Guardian Signature:
*
Printed Name:
*
Date:
*
PAYMENT POLICY & PAYMENT METHODS
A 50% non-refundable deposit is required at the time of registration to reserve your child's place in the program. The remaining 50% balance is due no later than one (1) day before the student's first scheduled lesson. All tuition must be paid in full before lessons begin. Little Ocean Aquatics reserves the right to postpone or cancel scheduled lessons if the balance has not been paid by the required due date.
Accepted Payment Methods • Cash • Zelle • Venmo • Cash App • Apple Pay
Payment Accounts:
Zelle:
Venmo:
Cash App:
Apple Pay:
By signing below, I acknowledge that I have read, understood, and agree to the payment policy. I agree to the Payment Policy.
*
Confirmar
OFFICE USE ONLY
Registration Date:
Student Level:
Instructor:
Office Use Only Continued
Program:
Start Date:
Payment Received:
Yes
No
Amount Paid:
Balance Due:
Enviar
