Please enter information in each of the boxes below. 

Use the TAB key to move from box to box

Click on the SUBMIT button at the bottom of this form when you are done.

Has anyone in your family taken lessons with us before? Yes   No

What is your family's last name? 

How many people in your family are you enrolling to be members?   

What are the first names and birthdates of the family members you are enrolling?  Don't forget to include yourself if you will be a member.  If you are enrolling more than six (6) members, please submit additional forms.  Thank you.

Member 1 First name           Birthdate (mm/dd/yy)     

Member 2 First name          Birthdate (mm/dd/yy) 

Member 3 First name          Birthdate (mm/dd/yy)    

Member 4 First name          Birthdate (mm/dd/yy) 

Member 5 First name          Birthdate (mm/dd/yy)    

Member 6 First name          Birthdate (mm/dd/yy) 

E-Mail Address   

Street Address     

City     State           Zip Code 

Home phone # (include area code)   

Work or cell phone # (include area code)  

How did you hear about us?

Thank you again for joining SWIM AND SCUBA!  We look forward to seeing you in the pool soon !!!!