Participants Name                                                                    Age                          Gender

Parent’s Name

Phone (H)                                                        (C)

E-Mail Address 

Home Address 

City                                      State                             Zip


Participant’s Skill Level                               Class Location and Day Preference

​New to SWIM4LIFE


Any Medical Conditions 


Consent For Medical Treatment

I do hereby give authority to the SWIM4LIFE staff to obtain necessary emergency medical treatment for myself/my child  with the understanding that the family will be notified as soon as possible.

Name  

Relationship to Participant                                         Date 

Emergency Name                                                    Phone 


CONSENT FOR USE OF PHOTOGRAPHY
SWIM4LIFE, at times will use photographs and other form of media for marketing and advertisement purposes.