FLORIDA PRIVATE LESSONS REGISTRATION Please enable JavaScript in your browser to complete this form.CONTACT INFORMATION:Name *Location *Select OneCape Coral, FLFt. Myers, FL.Cell Phone *Email *Name and Address of Home, Community, Condo, or Vacation Pool *Address Line 1CityChoose StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmergency Contact *Cell Phone *PRIVATE SWIMMER REGISTRATION:Name *D.O.B *Age *Gender *ChooseMaleFemalePREFERRED TIME SLOT:START DATE: *PREFERRED DAY *Choose DayMONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAYSATURDAYSUNDAYPREFERRED DAYChoose DayMONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAYSATURDAYSUNDAY (2nd choice - optional)PREFERRED TIME *Choose TimeMorning between 9am - 11amAfternoon between 12pm - 3pmEvening between 4pm - 7pmMONTHS AVAILABLE? Check all that applyNovemberDecemberJanuaryMarchAprilMayParticipation in Ocean City Aquatics is intended to promote healthy and safe swimming opportunities for myself, child and or children. Like many physical activities, swimming and associated activities pose certain inherent health risks that can result in serious injury (physical and/or emotional) or even death. I acknowledge and assume the risk inherent with myself, child/children active participation in Ocean City Aquatics. Failure to follow safety instruction may lead to my child/children suspension or cancellation of swim instruction. Discretion is left entirely to the Ocean City Aquatics staff to determine whether and when removal is appropriate. I give consent and permission for the taking of photography and/or video and/or audio of participants to be utilized for instruction and/or advertisement. Release and wavier: By signing this form, I acknowledge that I have been informed about certain risk and responsibilities in this program. I am acknowledging that I am knowingly and voluntarily assuming the risk. Further, by signing this form, I also agree, for myself, my heirs and assigns to release and hold harmless Ocean City Aquatics its employees and agents, from any legal claim or liability for any bodily injury and personal property damage that is caused to me by the negligent act or omission of persons not a party to this agreement. I further understand that my child/children cannot be left unattended during swim instruction. This waiver applies to all current and future swim classes and/or lessons taught by Ocean City Aquatics.PAYMENTPrivate lessons are $50.00 per swimmer / lesson.Payment Method *Choose your payment methodCheckCashPlease mail check payable to Ocean City Aquatics:5905 Tarpon Gardens Circle, Unit 202, Cape Coral, FL. 33914Please bring your cash payment to your first lesson. Parent or Guardian Signature (use mouse or finger to sign | x in upper right corner will clear the box) *Clear SignatureVerification * I have read and agree to the Participation, Release and Wavier.Security Verification * Type the word SWIM in the box below (this helps us cut down on spam)CommentSubmit
