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. 
Location and instructor choice *
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. *
Has this child ever been seen by a therapist (this includes physical therapist.)? If YES is selected, please give details below. *
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, Brittany Merring, Independent Swim Instructor. As a parent/guardian of a participant in Pediatric Survival Swim/ Allison Hogue's swim lessons, Brittany Merring'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, Brittany Merring, and Homeowners, harmless from any liability resulting from the use of premises and waive and relinquish all claims against Pediatric Survival Swim, Allison Hogue, Brittany Merring, 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, or Brittany Merring. 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 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.* *
Financial Agreement

Lessons are taught at your child’s emotional and physical pace, averaging 6-8 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 through the website
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!