2021 Registration

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

Please refer to plans as described in previous communications.

Swim Plan: Plan 1 – Early BirdPlan 1 – Not So Early BirdPlan 2 – EveningPlan 3 – Mixed

Medical Information

Doctor’s Name:

Phone Number:

Emergency Contact Name:

Emergency Contact Phone:

Medical Conditions:

Medications we should be aware of: