subject_line
Registration / Medical Review 2023
Boston (area), MA
Thank you for choosing Watch Me Swim. You are registering for lessons with Alicia Brown. All information is strictly confidential and will never be shared with another party.
BEFORE YOU BEGIN: Please email your Instructor, Alicia Brown before you complete this registration form at alicia@watchmeswim.com.
Student One Information
Student's Last Name
*
Student's First Name
*
Age in months/yrs:
*
Date Of Birth:
Must be atleast 6 months of age and be able to sit unassisted.
*
Gender
*
Male
Female
Choose Level That Fits Best
*
1st Year New Student - No formal lessons
1st Year New Student - Previous lessons at a traditional program
2nd Year Student - Previous ISR student
Not Sure - None of the above fit my child's skill level
Please Describe All Previous In Water Experience
*
🛈
0/300 characters
Does this child attend daycare/preschool either full time or part time?
*
Yes
No
Name of Preschool/Daycare:
Scheduling Comment?
Student One Health Information
Name of Student's Pediatrician or Primary Health Care Physician
*
Has
This Student Ever Been Seen By A Medical Specialist Other Than His Pediatrician?
*
Yes
No
If Yes, Please Explain & Include Date of Last Visit
0/300 characters
Does this student have any health issues or concerns such as allergies, current medications, therapy, history of seizures, etc.
*
Yes
No
If Yes, Please Explain
0/300 characters
Will You Be Registering A 2nd Student?
*
Yes
No