Registration Form 2012

Child/Children Information:

*Name: *Birthdate:
                (First & Last Name)                                          (Month/Day/Year)

   Name:    Birthdate:
                (First & Last Name)                                          (Month/Day/Year)

Home Pool: Access to Pool:
*Previous Swimming Lessons: Yes No
*Potty Trained: Yes No

*Medical Information:

(Please Provide a Doctor’s Note if needed to the Office
before your first lesson.)

Parents Information:
*Mothers Name:		*Fathers Name:
*Address:		*City:
*State:		*Zip Code:
*Home Phone:		*Mother (Cell):
*Father (Cell):		*Email Address:

*Location Requested:
Palm Beach Gardens / Jupiter Location
        (Offers Monday - Saturday)
Wellington (Monday thru Thursday)
Acreage / Loxahatchee (Offers Monday - Thursday)

*Please Choose the Lessons Desired:
Two 15 Minute Lessons
Three 15 Minute Lessons
Four 15 Minute Lessons
One 30 Minute Lessons
Two 30 Minute Lessons
One day a week on Saturday (Palm Beach Gardens Location Only)

*Please Indicate Time of Day that is best for your Child:

*How did you hear about Kids 1st Swim School:
Friend
Yellowbook.com
School Flyer
Postcard In Mail
YellowPages.com
Internet Search
Magazine Ad
Other:

* By checking this box I agree to the following Policy, Terms and
         Conditions.
         Please see our Water Safety Tips for more information.

Here at Kids first we would like to welcome you to another great year. We look forward to working with you and your children. Please remember that time slots are limited by Location and will be filled on a first come basis.

We accept the following Forms of Payment:

Visa, Master Card, American Express and Cash
Checks (Please Make Checks Payable to Kids 1st Swim School, LLC)

First payment:

Registration:
$30 Registration for 1 child
$40 Registration for 2 or more children
(The Office will call to set up the Lessons once the Registration Form has been filled out and submitted.)

*Security Code:
   Type THESE NUMBERS exactly as they appear:

* Required

M/C, Visa, and American Express Accepted