Pre-Registration Form Parent or Guardian Information:Ms. or Mr. (select one) * Required Ms. Mr. First Name * Required Last Name * Required Address * Required Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone * RequiredCell Phone * RequiredEmail (we will keep your email completely private) * Required What is your location preference? * RequiredPlease SelectSan RamonWalnut CreekHow did you hear about us? Student Information:Student #1 First Name * Required Student #1 Last Name * Required Student #1 Date of Birth * Required MM slash DD slash YYYY Student #1 Male or Female? * Required Male Female What days do you prefer for Student #1? Check all that apply. * Required Monday Tuesday Wednesday Thursday Friday Saturday Sunday What time of day do you prefer for Student #1? Check all that apply. * Required 8:00 AM - 12:00 PM 12:00 PM - 4:00 PM 4:00 PM - 7:00 PM 4:00 PM - 7:00 PM and Weekends Registration Status: Is Student #1 New or Returning? * Required New Returning For NEW Student #1, please check all that apply: Little or no previous water experience Enjoys the water and can put face in comfortably Can swim 10 feet independently and with eyes down in the water Can swim 36+ feet across the pool, breathing comfortably Can jump in and swim back to the wall unassisted Can back float Can kick on back across the pool Is comfortable in deep water Can dive head first from the side of the pool safely Can swim freestyle with good side-breathing for 36+ feet Can swim backstroke for 36+ feet Can do dolphin kick for 36+ feet Can swim elementary backstroke for 72 feet Can do some or all of the 4 competitive strokes, for 72 feet each Has Returning Student #1 had any lessons or participated on swim team since their last class at Splash? Yes No If you answered yes for student #1 having lessons or swim team experience, please indicate where: Do you need to register a second student? Yes No Student #2 First Name Student #2 Last Name Student #2 Date of Birth MM slash DD slash YYYY Student #2 Male or Female? Male Female What days do you prefer for Student #2? Check all that apply. Monday Tuesday Wednesday Thursday Friday Saturday Sunday What time of day do you prefer for Student #2? Check all that apply. 8:00 AM - 12:00 PM 12:00 PM - 4:00 PM 4:00 PM - 7:00 PM 4:00 PM - 7:00 PM and Weekends Registration Status: Is Student #2 New or Returning? New Returning For NEW Student #2, please check all that apply: Little or no previous water experience Enjoys the water and can put face in comfortably Can swim 10 feet independently and with eyes down in the water Can swim 36+ feet across the pool, breathing comfortably Can jump in and swim back to the wall unassisted Can back float Can kick on back across the pool Is comfortable in deep water Can dive head first from the side of the pool safely Can swim freestyle with good side-breathing for 36+ feet Can swim backstroke for 36+ feet Can do dolphin kick for 36+ feet Can swim elementary backstroke for 72 feet Can do some or all of the 4 competitive strokes, for 72 feet each Has Returning Student #2 had any lessons or participated on swim team since their last class at Splash? Yes No If you answered yes for student #2 having lessons or swim team experience, please indicate where: Do you need to register a third student? Yes No Student #3 First Name Student #3 Last Name Student #3 Date of Birth MM slash DD slash YYYY Student #3 Male or Female? Male Female What days do you prefer for Student #3? Check all that apply. Monday Tuesday Wednesday Thursday Friday Saturday Sunday What time of day do you prefer for Student #3? Check all that apply. 8:00 AM - 12:00 PM 12:00 PM - 4:00 PM 4:00 PM - 7:00 PM 4:00 PM - 7:00 PM and Weekends Registration Status: Is Student #3 New or Returning? New Returning For NEW Student #3, please check all that apply: Little or no previous water experience Enjoys the water and can put face in comfortably Can swim 10 feet independently and with eyes down in the water Can swim 36+ feet across the pool, breathing comfortably Can jump in and swim back to the wall unassisted Can back float Can kick on back across the pool Is comfortable in deep water Can dive head first from the side of the pool safely Can swim freestyle with good side-breathing for 36+ feet Can swim backstroke for 36+ feet Can do dolphin kick for 36+ feet Can swim elementary backstroke for 72 feet Can do some or all of the 4 competitive strokes, for 72 feet each Has Returning Student #3 had any lessons or participated on swim team since their last class at Splash? Yes No If you answered yes for student #3 having lessons or swim team experience, please indicate where: Comments, or let us know if you have more children to pre-register, our office will give you a call.Click the button below to submit your Pre-Registration information to Splash Swim School! Get Started with Swimming Lessons Today at Splash Swim School Call Now
