2012 Lifestyle Swim School Registration by Credit Card

Payment Information:

First and Last Name on card     

Participant's Total USD $

Master Card or Visa Card: type 4 numbers then a -, 4 times for a total of 16 numbers (example:1234-5678-1234-5678)

Expiration date: 2 digit month/2 digit year       3 digit Security Code on back of card 
 

Zip code used for card statements

By completing this registration form and filling in date below you agree to the following waiver and release:

The undersigned agrees to defend, pay and save free and harmless Lifestyle swim school, Inc., the facility owners where lessons are conducted and their respective agents, employees' actions, judgments and proceedings of any kind or in favor of anyone whomsoever and from and against all injury or property damage arising directly or indirectly out of, from or on account of applicant's presence at or use of the facilities or participation in any activities or programs applied for hereby or at any time hereafter. My child (children) has been examined by a certified physician within the last year and is physically fit to participate in swim lessons. He or she is free from any contagious disease. I understand missed classes may not be carried over to the next session. I understand that the lifestyle Swim School is unable to grant refunds. We reserve the right to: accept only those families who abide by our patient child-centered philosophy; to expel those families that do not abide by the philosophy, fail to follow rules, use foul language, or are disrespectful to teachers, staff or fellow classmates.   Date:

Mother's Contact Information:

Mother's first and last name  

Mother's email:   Website

Home telephone (including area codes)    Cell Phone 

Occupation   Employer

Father's Contact Information:

Father's first and last name  

Father's email:   Website

Home telephone (including area codes)    Cell Phone 

Occupation   Employer

Family's address:

Street, city, state, zip  

Child Information:

First child:  first and last name 

Age and date of birth 

Briefly describe water experience

Class name/Session number/date

Days/class time/location 

2012 Registration fee $35 plus class fee and total dollar amount

Any special conditions, needs, requirements, health concerns, questions or assistance needed

Second child: first and last name 

Age and date of birth 

Briefly describe water experience

Class name/Session number/date

Days/class time/location 

2012 Registration fee $25 plus class fee and total dollar amount

Any special conditions, needs, requirements, health concerns, questions or assistance needed

Third child: first and last name 

Age and date of birth 

Briefly describe water experience

Class name/Session number/date

Days/class time/location 

2012 Registration fee $15 plus class fee and total dollar amount

Any special conditions, needs, requirements, health concerns, questions or assistance needed

How did you hear about us?

If there are questions about your registration you will be contacted prior to processing.

Questions: Email   mckayswim@aol.com or phone: 1-561-393-6386