La Vita Swim Lessons Child Enrollment

La Vita Swim Lessons Child Enrollment

Please complete a new form for each child enrolled in program.
Child's Name

First NameLast Name
Parent / Legal Guardian's Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Individuals Allowed to Drop-off / Pick-up Child
Individual 1

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Child
Individual 2

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Child
Individual 3

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Child
Individual 4

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Child
Child's Medical Information
Child's Birth Date

MonthDayYear
Gender of Child
Allergic Sensitivities
Medical Conditions
Activity Limitations
Please describe limitations:
I hereby acknowledge that all information contained on this form is accurate and current. Furthermore, I understand and agree to update any of this information as needed.
Parent / Legal Guardian Signature
Should be Empty:

Individuals Allowed to Drop-off / Pick-up Child