New Registration | Ped Survival Swim

Registration

Student Information:

Student Name

Student Birthdate

Gender

Male

Female

Relationship to Student

Mother

Father

Grandparent

Other

Instructor / Location Preference

Allison / Bradenton

Brittany / Sarasota

No Preference

Contact Information:

Cell Phone Number

Text Msg Communication?

Yes

Street Address

Street Address Line 2

City

Postal / Zip code

Occupation

Person Responsible for bringing the Student to classes:

First and Last Name

Relationship to Student

Mother

Father

Grandparent

Other

Student Health Information

Health Information:
We ask that you try and 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.

Pediatrician

Pediatrician Phone #:

Has this child ever been referred to a specialist of any kind? If YES is selected, please provide details below.

Yes

Has this child ever seen a therapist (this includes physical therapist)?

Yes

What is the intended aquatic goal for this student?

What is your preferred swim lesson time and start month? Please add two options for swim times.

How did you find Pediatric Survival Swim?

Do you have any additional information or requests not already mentioned on this form?

Participation Agreement

I _______ am the Parent /Guardian of this student.

Waiver
To participate in aquatic activity. My child is in good health and physical condition and is 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 participation in this program, you will be waiving and releasing all claims for injuries you or your child might sustain as a result of participation in any class or activity conducted by Pediatric Survival Swim, Allison Hogue, and all Independent Swim Instructors working under the Pediatric Survival Swim name. As a parent/guardian of a participant in Pediatric Survival Swim/ Allison Hogue's swim lessons, 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 Any Independent Swim Instructor working under the Pediatric Survival Swim name, Allison Hogue, 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, Allison Hogue swim lessons, any Independent Instructor working under Pediatric Survival Swim. I have read all material and fully understand the above waiver and release of all claims, and it shall not be modified orally.

Your Signature

Date

Financial Agreement
I as the parent or legal guardian understand that lessons are taught at the child's emotional and physical pace, averaging 6-8 weeks in length. Sometimes lessons can continue longer if the child has missed too many classes, keeping them from building muscle memory. Lessons can begin any month based on our availability and your scheduling needs. We recommend scheduling your class in advance to ensure you get the time you need and avoid your child being placed on a waitlist.
Occasionally, factors such as bad weather or sickness could cause a delay in your start date. Your instructor will notify you if there is any change to your start date.
Please be aware that when you sign up for the lessons below, you are signing up for several WEEKS of lessons. The duration of your lessons will depend upon the type of lessons you have chosen.
Any instructor cancelations or bad weather days will be added to the END of your child's program.

Tuition and Registration are non-refundable and up to the instructor's discretion.

Your Signature

Date

Photo/Videography
Photos and videos (many of which are 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/grandparent/legal guardian) understand that if you agree, video/picture media may be used for informational advertising purposes. Whenever possible those photos and videos will be shared with parents. 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.

Your Signature

Date

I acknowledge 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 are not giving authorization for video and photos.

I accept the terms & conditions outlined in the waiver, financial agreement and photography agreements above.

Please Type full legal name below to acknowledge agreement

Registration fee for the program is $95

Thanks for registering!