Participants Name Age Gender
Phone (H) (C)
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.
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.
What program are you registering for