Pediatric Survival Swim Registration

Welcome, and thank you for choosing Pediatric Survival Swim.

Please complete the following New Student Registration form, Please be aware that there is a $95 new student registration fee.

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.

Students first and last name:

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:

What is the intended aquatic goal for this child?

What is the preferred swim time and month you would like to start lessons?

How did you hear of 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

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 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 might sustain as a result of participating in any class or activity conducted by Pediatric Survival Swim, Allison Hogue, Brittany Merring, Christina Mizell, 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 idemnify and hold Pediatric Survival Swim and any Independent Swim Instructor working under that Pediatric Survival Swim name, Allison Hogue, Brittany Merring, Christina Mizell, or 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:

Financial Agreement

I as the parent or legal guardian, understand that lessons are taught at the child's emotional and physical pace, which averages 8 weeks in length. (Please note that children with special needs can be much longer as they require more time and attention in the water.) Sometimes lessons can continue longer if the child has missed too many lessons, keeping them from building muscle memory. Lessons can begin any month based on our availability. 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 are any changes 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.

Cancellations: Because we have substantial waitlists, we can only accept up to 3 cancellations unless prior notice has been communicated to your instructor weeks in advance. We do understand there are uncontrollable circumstances. Please communicate this to the management team if this is the case.

No shows and cancellations less than 24 hours in advance are automatically charged as a swim day.

Any instructor cancellations or bad weather days will be added to the following week's tuition.

Late fees: All tuition is due by Sunday night. We do charge late fees of $2 per day unless you are auto-pay.

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

Signature

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Date

Month

Day

Year

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.

Fixed price

$95