2-Week Group Lesson Registration

Childs Name

Childs D.O.B

Age

Gender

Male
Female

What is your child's swim level?

Does your child have any fear or anxiety around the water

Can your child put their face in the water?

Can your child swim unassisted?

Can your child take a independent breath while swimming?

Any previous swim lesson experience?

What distance can your child swim?

Parent/Guardians Name

Are you an employee?

Yes
No

Is your child in summer camp at PAC?

Yes
No

If YES, please let Playland know when you drop your child off.

Address

Address Line 1

Address Line 2

City

State

Zip Code

Work Phone

Cell Phone

Email *

Member *

$190/per child
I'm not a member

Non-Member *

$220/per child
I'm a member

All non-members must make an appointment to sign a guest waiver and pay in person. Email: charlotte.boswell@genesishealthclubs.com

What session would you prefer

Choice what time you would like the sessions

Payment Info

Signature *

Clear Signature

I accept full responsibility for my use of any and all apparatus, appliances facility privilege or service whatsoever, owned and operated by this Club at my own risk and shall hold this Club, its shareholders, directors, officers, employees, representatives, and agents harmless from any and all loss, claim, injury, damage or liability sustained or incurred by me resulting therefrom. By completing this form you agree that we may communicate with you by phone, or by using electronic communications such as email and text messaging. Your information will not be sold by Genesis Health Clubs.

Date / Time

Date

Time

Will any other adult bring or pick up your child from swim lessons?

Yes
No

Additional Authorized Adult’s Phone (1)

Authorized Adult’s Full Name (1) *

First

Last

Authorized Adult’s Waiver Signature *

Clear Signature

I accept full responsibility for my use of any and all apparatus, appliances facility privilege or service whatsoever, owned and operated by this Club at my own risk and shall hold this Club, its shareholders, directors, officers, employees, representatives, and agents harmless from any and all loss, claim, injury, damage or liability sustained or incurred by me resulting therefrom. By completing this form you agree that we may communicate with you by phone, or by using electronic communications such as email and text messaging. Your information will not be sold by Genesis Health Clubs.

Promotional Code (Optional)