Registration Form

$25.00 non-refundable registration fee due before the first class.

Swimmer’s Name: ____________________ Date of Birth: __________ Age: _____

Mom’s Name: _______________________ Dad’s Name: _______________________

Home Address: _______________________________________________________

Home Phone: _______________________ Work Phone: _______________________

Cell Phone: _________________________ Other Phone: ______________________

Email: ____________________________ 2^nd Email: _________________________

How did you hear about “Can Do” Swimming?: _________________________________

* Please read the following and sign the bottom if you are in agreement.

Payment for the class is due in full at the first lesson. Refunds will not be given after that first lesson. If I (April Balch) can not complete teaching the course a refund will be given for the remaining untaught classes. In the case of inclement weather the class or classes will be rescheduled.

_____________________________________ _______________________________________

Swimmer/Parent’s signature April Balch, W.S.I. American Red Cross

9723 Galston Lane

_______________________ Spring Texas 77379

Date 281-655-1246 or 832-444-4630

CHECKS PAYABLE TO: April Balch Course Completed: _____________________

Amount Paid: $__________ (For Internal Use Only)

Cash or Check #__________