Pediatric Survival Swim Voucher Registration

Welcome, and thank you for choosing Pediatric Survival Swim.

🛑 STOP! Please make sure you have been in contact with us about openings in the schedule and or the current waitlist! (940)-867-6360 calls/text for scheduling details.

Swim voucher clients are not offered travel!

WE DO NOT OFFER MAKE-UP CLASSES FOR VOUCHERS. ATTENDANCE IS A MUST. ONLY 1 ABSENCE ALLOWED FOR THIS SHORT PROGRAM TO MEET THE DEMAND FOR CLASSES!

👀Each child must have their own registration form per insurance requirements!! 👀

Please be as accurate and specific as possible so we can assess how to best serve your student. Some answers provided may lead to a swim release, which will need to be provided by the child's Ped. or specialist before lessons are to begin. We will contact you if this is the case.

LESSONS ARE 4x per week MONDAY-THURSDAY! Booking is required on Friday before the lessons start.

What to Expect: Our Approach to Survival Lessons

The First Week: Bonding and "Work" Our priority is building a foundation of trust. The first few days of lessons include snuggling, play, and intentional bonding to help your child feel secure with their instructor. However, because these are life-saving skills, we do get to work immediately; this includes submersion on the very first day to begin building vital breath control. Because this is a new "workday" for your child, it is very common—and developmentally normal—for them to cry during the first week. Please understand that this crying is a form of communication and protest against a new task, not a sign of distress or a lack of safety.

Your Role: The "Quiet Anchor" To help your child move past the crying phase and gain independence, we need you to be their "Quiet Anchor." While it is tempting to cheer loudly or call out to your child, this actually distracts them and encourages them to "reach" for a rescue rather than focusing on their skills. We ask that you remain a calm, silent observer. Your quiet, neutral presence signals to your child that you are not worried and that they are safe to bond with their instructor. By staying committed and calm during this initial "hurdle," you allow your child to transform from unskilled to water-safe.

I have read and fully understand the expectations of the first week of lessons.

Students first and last name:

Swim Voucher #

Parent/ Guardian first and last name:

Birthday of student

Month

Day

Year

Gender

Male

Female

Phone

Address

Parent/Guardian Occupation:

Please provide names and numbers of all adults bringing the child to lessons

Health Information

We ask that you try to be as accurate as possible. We never share information about our clients. This information is used only to provide accurate information for the instructor. These results may potentially alter the length of your child's program. We see many clients who receive multiple health services. We need to make sure we are not interfering with any medical professionals, especially therapies.

Pediatricians name and number:

Has this child ever been referred to a specialist of ANY kind? if YES is selected, please provide details below:

Yes

If selected YES, please provide details here:

Is your child receiving services of any kind? Please list below:

Has your child ever had a breath holding spell either voluntarily or involuntarily?

Has your child ever had a seizure?

Was your child born before 38 weeks gestation?

Has your child ever been hospitalized or had any surgeries using anesthesia?

Has your child ever been evaluated for, or diagnosed with, any developmental delays, learning differences, or special needs? Sharing this information helps us tailor our care and environment to their unique strengths.

Does your child require or need any special accommodations for them to be successful within our program?

What is the intended aquatic goal for this child?

Has your child been in lessons previously? If so, what facility, instructor, or program was your child apart of? How long did your child participate in these lessons? How did your child respond to the lessons?

Does your child use floaters, puddle jumper, life jacket, or any floatation device that is strapped to your child? This does not include on the boat, just in the pool during swim time.

During this program, we do not allow the swim student to use a floatation device of ANY kind while in the swim program. Only swimming WITH an adult is allowed. All devices place children in the vertical swim posture where they will develop muscle memory in an incorrect swim position. This causes the child to unlearn all that we have taught them in a matter of hours. Only coast guard approved life jackets can be worn only on boats, open water, kayaking, and canoeing. Please do NOT swim in them but keep them dry to ensure your child’s swim skills stay enact. If you use these devices you could extend your child’s swim lessons with us by up to 50% longer. Which can also be a financial burden on your family. Therefore, please only swim with your child and skip ALL Floaties! This will ensure your child can succeed in a timely manner without any confusion to the child.

What is the preferred swim time and start date? Please make sure your start date does not conflict with any vacations you have planned. We do not want any interruptions during your child’s program. Please choose a time range or add “flexible.”

Would you like in-home lessons or lessons at our location?

If you would like in-home lessons. Please add the address of where lessons will be held. Please include any gate codes, parking info, and where to enter at to access the pool.

How did you hear of Pediatric Survival Swim?

Do you have any additional information or requests not already mentioned on this form? Any specific notes for the instructor?

If you have any known missed days planned please let us know below. Please account for any vacations before you book so that you are not charged for more than the allotted 2 days.

Participation Agreement

I ______ am the Parent/ Guardian of this student

Signature of parent/ legal guardian

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Date

Month

Day

Year

Waiver

To participate in aquatic activity. My child is in good health and physical condition as well as the parent attending the parent in-water class, and not suffering from any condition that would prevent him/her from engaging in this activity.

Please read carefully and be aware that in registering your minor child for participating in this program, you will be waiving and releasing all claims for injuries you or your child/ any member of household could sustain as a result of participating in any class or activity conducted by Pediatric Survival Swim, Allison Hogue, Brittany Merring, Christina Mizell, Angela Tirpak, Katja Borosch, and all Independent Swim Instructors working under the Pediatric Survival Swim name. I recognize and acknowledge that there are certain risks associated with these lessons. I agree to indemnify and hold Pediatric Survival Swim and any Independent Swim Instructor working under that Pediatric Survival Swim name, Allison Hogue, Brittany Merring, Christina Mizell, Angela Tirpak, Katja Borosch, and any homeowners, harmless from any liability resulting from the use of premises and waive and relinquish all claims against Pediatric Survival Swim, Allison Hogue, and the pool owners that I or my minor child/children (swimming or not) may sustain while on the property or personal residence or as a result of participating in any form of swimming program offered by Pediatric Survival Swim, Allison Hogue, or any independent instructor working under Pediatric Survival Swim. I have read all materials and fully understand the above waiver and release of all claims, and it shall not be modified orally.

I acknowledge that formal swim lessons are a vital layer of protection but do not make a child 'drown-proof.' I understand that while lessons can reduce the risk of drowning by up to 88%, they are only one of many necessary layers of water safety. I agree that swim skills are never a substitute for active adult supervision and commit to ensuring my child is never left unsupervised around water, regardless of their swimming ability.

Signature

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Please type full legal name:

Acknowledgement of Program Scope & Swimming Safety Waiver

By signing below, I acknowledge and agree to the following conditions regarding the Department of Health Swim Voucher Program:

Introductory Scope: The 8-16 free swim lessons provided through the Swim Voucher Program are designed purely as an introductory course to water familiarization and basic mechanics.

Incomplete Survival Skills: This introductory course does not complete a comprehensive Survival Swim program, nor does it render a child fully skilled or proficient in independent water survival.

Necessity of Continued Instruction: Eight-sixteen lessons are insufficient to make a child fully safe in, on, or around water. Continued, consistent swim instruction is strongly recommended to build adequate safety and swim skills.

No Guarantee of Water Safety: No amount of swim lessons can make a child completely "drown-proof." Completion of this program does not guarantee my child's safety in the water, and active adult supervision is always required around any body of water.

Release of Liability: I assume all risks associated with my child's participation in this introductory program and agree that the facility, its owners, and instructors are not liable for actions, injuries, or incidents occurring outside or after the completion of these 8 introductory sessions.

Signature for Voucher Program

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Date

Month

Day

Year

Parent/Guardian In-Water Participation & Liability Waiver

By signing below, I acknowledge and agree to the following conditions regarding standard pool safety and in-water participation:

Mandatory Adult Participation: I understand that a parent or designated adult guardian must accompany the child into the water for designated parent-child sessions and actively participate throughout the class.

Personal Physical Readiness: I confirm that I am physically capable of participating in in-water activities and handling my child safely in a pool environment.

In-Water Risk Assumption: I voluntarily assume all risks associated with entering the pool area and participating in the water, including but not limited to slips, falls, accidental submersions, or personal injuries.

Pool Rules Compliance: I agree to follow all posted facility rules, pool safety protocols, and direct instructions given by the swim staff at all times.

Release of Liability for Participants: I release and hold harmless the facility, its owners, and staff from any claims or liabilities resulting from my personal participation in the in-water class.

Signature

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Photo/Videography

Photos and videos (many of which are taken underwater,) may be taken in conjunction with lessons by your instructor. Video use is for training and review to improve your child's lessons. I (parent/ legal guardian) understand that if you agree, video/picture media may be used for informational advertising purposes. If you do NOT wish for any pictures or videos to be taken of your child, please write NO in the signature. We respect your right to privacy.

Signature

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Please note that any video taken from the poolside needs to be approved by Pediatric Survival Swim before being shared on social media, as it may contain other children and or non-swimmers that have not given authorization for video and photos.

Policy Regarding Firearms and Weapons

For the safety and security of all children, families, and staff, our facilities, pool premises, and surrounding property are designated as a weapons-free zone.

Firearms, ammunition, or any other weapons are strictly prohibited and are not permitted on the premises at any time, regardless of any state or local laws allowing unlicensed carrying or firearms in public spaces. This policy is non-negotiable and is implemented to maintain the most secure and developmentally appropriate environment possible for our students, who are primarily young children learning survival skills.

Any violation of this policy will result in immediate termination of lessons and access to our facility, without a refund.

I have read the Fire Arms and Weapons Policy.

I agree to the terms and conditions.