Survival Swim Registration 2024

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2024

Today's Date *

Email Address *

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New student

Returning Student

Child First Name *

Last Name *

Birth date *

Current age *

Sex *

Male

Female

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Parent Name *

Last Name *

SEX *

Milestone's

What Age did your child sit unassisted? *

At what age did your child stand unassisted? *

What age did your child walk 3ft. unassisted? *

Developmental Milestones are important to us when assessing a timeline for completion of your childs skills. Please provide the most accurate information as possible. If you feel your child was delayed in achieving any of the above , Please provide a detailed explanation in the box below. Please put N/A if it does not apply.

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Physician Information

Physician's name *

Phone *

Has he/she EVER been under the care of a medical specialist other than a pediatrician? *

Yes

No

If YES please explain. Please put N/A if it does not apply. *

Has he/she ever received a diagnosis of a medical condition by a specialist other than a pediatrician? *

Yes

No

If YES please explain. Please put N/A if it does not apply. *

Has he/she ever experienced a seizure or other abnormal neurological event? If yes, when and what was the determination of the cause by the doctor? Please add Dates of last Seizure. *

Yes

No

If Yes please explain. Please put N/A if it does not apply. *

Has he/she ever been diagnosed with a seizure disorder? *

Yes

No

If YES please explain. Please put N/A if it does not apply. *

Has he/she ever been diagnosed with a heart murmur or other heart related condition? *

Yes

No

If yes please explain. Please put N/A if it does not apply. *

Does he/she occasionally and/or routinely use any OTC (over-the-counter) medications including Benadryl, Zyrtec, etc.? *

Yes

No

Is he/she currently on any PRESCRIPTION medications? Please list below. Please put N/A if it does not apply. *

Does he/she have any food and/or environmental allergies? *

Yes

No

If Yes please explain. Please put N/A if it does not apply. *

Does he/she require the use of an Epi-pen? *

Yes

No

If YES please explain. Please put N/A if it does not apply. *

Swim History/ Liability/ Photo consent

Has this student ever been in a floatation device or any other swim program?

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How did you here about us? *

Family/Friend

Facebook

Other

Website

Please give name so we can thank them.

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This enrollment is for informational purposes only to provide the safest lesson possible to your children. A note from your child's doctor may be required prior to participating in lessons. Bonnie Cannon is not responsible for evaluating a child's medical fitness level to be able to participate in the program. If information is not provided on this form, You instructor Bonnie Cannon will not be responsible for undisclosed information. If at any time during your participation in lessons your child is prescribed medication, it is your responsibility to contact your instructor Bonnie Cannon 832-366-3008 *

I Agree

I Disagree

PHOTO/VIDEO CONSENT I hereby grant the Company and its representatives the right to photograph and/or videotape me and/or my child and to use my child's or my name, face, likeness, voice and appearance in connection with exhibitions, publicity, advertising, promotional and commercial materials without reservation or limitation. The Company and its representatives, however, are under no obligation to exercise said rights. Sharing of Photos and/or Videos: The Company prohibits the posting of lesson pictures and/or videos on YouTube or any other public forum unless permission has been granted prior to use. Parents may share lesson pictures with friends and family so long as it is not via a public forum. *

YES! I give my consent

No! I do not give my consent

Your signature is to certify all the information you have provided is true and accurate to the best of your knowledge and belief. You also agree if your child becomes ill and needs to be seen by any dr. while in lessons, You will contact Bonnie Cannon 832-366-3008 immediately to provide any necessary information. Please sign your name with your mouse in the box to certify all the Information you have provided is true and accurate to the best of your knowledge and belief. RELEASE OF LIABILITY In consideration of being allowed to participate in the Company's program, related events, and activities, I, the undersigned parent or legal guardian of a child participating in the program, acknowledge that the risk of injury involved in this program could be significant, and knowingly and freely assume all such risks, known and unknown, even if arising from the negligence of the Company, the instructor, or others, and assume full responsibility for my child's and my participation therein, and I, for my child and myself, and on behalf of my/our heirs, assigns and personal representatives, hereby release, indemnify and hold harmless the Company, its owners, officers, directors, employees and independent contractors, with respect to any and all injury, disability, death, loss or damage to person or property as a result thereof, to the fullest extent permitted by law. I have read and fully understand this release of liability and assumption of risk and am signing it freely, voluntarily, and without inducement *

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Registration and lesson fees

Registration Fees. Please note that Registration Fees are NON REFUNDABLE. If you have not registered your child in the last 12months. Please register as a new student. Please understand that all start dates are tentative and subject to change due to TX weather or unforeseen circumstances. *

New Student $85.00

Returning Student $45.00

Late Payment fee! Their will be a $15 per day fee added to all late payments. Payments are due on the first day of lessons. (No exceptions) *

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Online Registration Fee: $85 (paid thru online) If you have not registered in the last 12months you must register as a new The weekly lesson rate is $120 The total lesson fee will depend on the sequence your child is learning and will therefore be Lesson Fees for New Students/ and returning floaters Paid in 2 installments. Weeks 1 - 4: $480 (due on first day of lessons) Weeks 5 - 6: $240 (due on last day of week 4) If your child only requires 5 weeks of lessons, then your second payment will only be $120 If your child requires 7 weeks of lessons, then your third payment will only be $120 If your child requires more than 6 weeks of lessons, then the remaining payments will be made on a weekly basis. All registration fees and weekly fees are non refundable due. No exceptions *

yes I understand

No I do not understand