Pediatric Survival Swim Registration

Pediatric Survival Swim Registration Form

Registration has a 1 time $95 fee per child.

Registration fees must be submitted before we can add your child to the swim schedule.

Welcome, and thank you for choosing Pediatric Survival Swim to provide survival swimming and problem-solving skills for your children.

Please complete the following New Student Registration form. Please be as accurate and specific as possible so I can assess how to best contour my teaching methods to fit the needs of your child. Some of the answers provided may lead to a swim release which will need to be provided by your pediatrician and or specialist. I will contact you if this is the case.

Participant Information

Student First and Last Name *

Gender *

Birthdate * +

Parent/Guardian Contact Information

First and Last Name *

Relationship to Participant: *

Mother

Father

Grandparent

Other Other

Text? *

Yes

Cell Phone Number *

Primary Email Address *

Address *

Zipcode *

Occupation *

Person Responsible for bringing the Student to classes

First and Last Name *

Relationship to Student *

Mother

Father

Grandparent

Other Other

Cell Phone Number *

Text? *

Yes

Email Address *

Health Information
We ask that you try and be as accurate as possible. We never share information about our clients. This information is used only to provide accurate information for the instructor. These results may potentially alter the length of your child's program. We see many clients who receive multiple health services. We need to make sure we are not interfering with any medical professionals, especially therapies.

Pediatrician Name *

Pediatrician Phone # *

Has this child ever been referred to or seen a specialist of any kind? If YES is selected, please give details below. *

Yes

Specialist information and reasoning. Does your child still receive these services? *

Has this child ever been seen by a therapist (this includes physical therapist.)? If YES is selected, please give details below. *

Yes

Please specify if checked, yes. Does your child still receive these services? *

What is the intended aquatic goal for your child?

Additional Information

What are your preferred swim lesson times and start month? Please place at least 2 options for swim times. *

How did you find Pediatric Survival Swim or Allison Hogue/ Swim Instructor?

If you have additional information or would like to request something not mentioned on this form please use this section.

Participation Agreement

I, ____________ (fill in your name here)

*

as parent, grandparent, guardian, give permission for my child ________________ (your child's name here) *

to participate in aquatic activity. My child is in good health and physical condition, and is not suffering from any condition that would prevent him/her from engaging in this activity. Please read carefully and be aware that in registering your minor child for participation in this program, you will be waiving and releasing all claims for injuries you or your child might sustain as a result of participation in any class or activity conducted by Pediatric Survival Swim, Allison Hogue, Independent Swim Instructor. As a parent/guardian of a participant in Pediatric Survival Swim/ Allison Hogue's swim lessons, I recognize and acknowledge that there are certain risks associated with these lessons. I agree to indemnify and hold Pediatric Survival Swim, Allison Hogue, Homeowners, harmless from any liability resulting from the use of premises and waive and relinquish all claims against Pediatric Survival Swim, Allison Hogue, and the pool owners that I or my minor child/children (swimming or not) may sustain while on the property or as a result of participating in any form of swimming program offered by Pediatric Survival Swim, Allison Hogue, Allison Hogue swim lessons. I have read all material and fully understand the above waiver and release of all claims, and it shall not be modified orally. Signature of Parent/Legal Guardian *

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Printed Name of Parent/Legal Guardian *

Date * +

Photo/Videography

Photographs and videos (many of which are underwater) may be taken in conjunction with lessons by your instructor. Video use is for training and review to improve your child's lessons. I (parent/grandparent/legal guardian) understand that if you agree, video/picture media may be used for informational advertising purposes. Whenever possible those photos and videos will be shared with parents.

If you do NOT wish for videos or photos to be taken and or shared throughout the program, please write NO in the box below.

*Please note that any video taken from the poolside needs to be approved by Pediatric Survival Swim before being shared on social media, as it may contain other children and or non-swimmers that are not giving authorization for video and photos to be taken.* *

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Financial Agreement

Lessons are taught at your child’s emotional and physical pace, averaging 6-7 weeks in length. Lessons can begin any month based on our availability and your scheduling needs. We recommend scheduling your class in advance to ensure you get the time you need and avoid your child being placed on a waitlist.
Occasionally, factors such as bad weather or sickness could cause a delay in your start date. Your instructor will notify you if there is any change to your start date.
Please be aware that when you sign up for the lessons below, you are signing up for several WEEKS of lessons. The duration of your lessons will depend upon the type of lessons you have chosen.
Any instructor cancellations or bad weather days will be added to the END of your child's program.
Tuition and Registration are non-refundable.

Please be aware that canceled classes are not refundable.

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Almost Finished...

Thank you for taking the time to complete the Student Registration. Please complete your form by paying your $95 registration fee. https://venmo.com/u/pediatricsurvivalswim NOTE: Paypal users will be charged an additional $2 per transaction. Cash, Check, Venmo, Apple pay, or Zelle do not require fees.

The Next Steps are:

1. Please download or print and carefully read through the Lesson Guide Packet. You can find the link on my webpage at pediatricsurvivalswim.com

You will find important information here regarding meal times, inclement weather policies, etc.

2. Children who are not FULLY potty trained will need to wear a non-disposable swim diaper.

You will be contacted after the completion of this registration and payment has been received to confirm or revise your date and time for your child(ren)

3. All parents/caregivers bringing the child to swim will need to come to the right side of the house and through the gate. I will be waiting at the pool. Please do not come to the front door. I will not answer as I am already in the pool.

Thank you and I look forward to meeting you and teaching your child to be safer in and around the water!