First Name:
Last Name:
Gender: FemaleMale
Birthdate: mm/dd/yyyy
Address:
City:
Province:
Postal Code:
Home Phone:
Cell Phone:
Email:
Were you referred by a member? YesNo
If yes, what is her/his name?
Swim Plan: 1/week2/week3 or more/week
Track: FitnessCompetitiveTri
Prefered days: Mon 7:30 pmTue 6:00 amTue 9:30 amWed 7:30 pmFri 6:00 amFri 9:30 amSun 7:30 am
Doctor’s Name:
Phone Number:
Emergency Contact Name:
Emergency Contact Phone:
Medical Conditions:
Medications we should be aware of:
