Pediatric Survival Swim Registration Form
Registration has a 1 time $95 fee per child. You will never pay registration again!   @pediatricsuvivalswim
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. 
Relationship to Participant: *
Text? *
Relationship to Student *
Text? *
Has this child ever been referred to or seen a specialist of any kind? If YES is selected, please give details below. *
0/500 characters
Do you vaccinate your child/ren? The answers to this question may determine scheduling on my part to ensure the health and safety of other students. *
0/255 characters
Has this child ever been placed in a floating raft/tube, or used water wings, sometimes referred to as arm bands, puddle jumpers or floaties? *
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 *

Photographs and video (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 and agree that this media may be used for informational advertising purposes. Whenever possible those photos and videos will be shared with parents.

I (parent/grandparent/guardian) agree that I will NOT post personal videos or photos on any social media site without the permission of Allison Hogue, Pediatric Survival Swim.

I (Parent/Grandparent/Guardian) agree to these photo/video terms *
Financial Agreement

Registration Fee

There is a $95 non-refundable registration fee per student, due at the completion of this form. The registration fee will hold a spot for your child(ren) on my schedule. 

Weekly Fees

Weekly tuition for all classes and courses are $100 per child per week. Weekly fees are due on Thursdays the week before each scheduled week of lessons. 

Payments can be made with venmo, cash, or check made out to Allison Hogue. All cash or check payments need to be placed in the white envelopes provided on the swim table and labeled the name of the child (ren) receiving the lessons.
All returned checks have a $40 return fee. I will receive the full payment amount in advance.
Venmo: @pediatricsurvivalswim

Parent/Guardian signature agreeing to financial terms *
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Thank you for taking the time to complete the Student Registration. Please complete your form by paying your $95 registration fee. 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
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!