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.
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.
Individuals Allowed to Drop-off / Pick-up Child
Individual 1*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship to Child*
Individual 2

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to Child
Individual 3

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to Child
Individual 4

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to Child
Child's Medical Information
Child's Birth Date*

MonthDayYear
Gender of Child*

MaleFemale
Allergic Sensitivities
Medical Conditions
Activity Limitations

YesNo
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*

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Should be Empty:

Individuals Allowed to Drop-off / Pick-up Child