Swim Registration TEST FORM | Pelican Athletic Club

Name *

First

Last

Date of birth

Age

Gender

Male
Female

Address

Address Line 1

Address Line 2

City

State

Zip Code

Are you an employee?

Yes
No

Home

Work

Cell

Which number is best to contact

Home
Work
Cell

Email *

Instructor Preference for Private and Semi-Private (if any)

Time Preference

AM
PM

Member (4/30 Min. Lessons) *

Private - $150.00
Group - $120.00
I'm a non-member

Non - Member (4/30 Min. Lessons) *

Private - $170.00
Group - $140.00
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

How would you like to pay (We will reach out for payment after form has been submitted)

PAC Account **Preferred**
Check (Check must be brought in to hold spot) | Must be paid in 48 hours to hold
Cash | Must be paid in 48 hours to hold
Credit Card | Must be paid in 48 hours to hold

Payment must be made to ensure your spot

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.

Today's Date / Time

Date

Time

Promotional Code (Optional)