Parent’s Name

Parent’s Email

Parent’s Cell Number

Child’s Name

Child’s Age

Child’s Previous Swimming Experience

Please list any allergies.

Are the child’s vaccinations up-to-date?
—Please choose an option—YesNo

Does your child have any special needs or developmental delays that we need to take into account?
—Please choose an option—YesNo
Please explain.

Child’s Physician Name

Physician Telephone Number

May we use your child’s photograph for our website and/or social media?
YesNo

I understand the $100 deposit per session to hold my child’s spot in a class is non-refundable.

I understand the balance of $225 (optionally included in my purchase on this website, cash, check – made payable to Jessica Kramer, or Venmo @Jessica-Kramer-23) is due on the first day of class.

I understand that there will be a $25 per-day late fee for balances not paid on time.

I understand that only classes that are rained out or cancelled by Swimmers by Jessica will be made up; no other make-ups.

Please type your first and last name if you affirm this statement. “I have enrolled my child in a swimming program of physical activity offered by Swimmers by Jessica. I hereby affirm that my child is in good physical condition and does not suffer any disability that would prevent or limit his/her participation in the program.”

Please type your first and last name if you affirm this statement. “In consideration of my child’s participation in Swimmers by Jessica, for my child, myself and assigns, I hereby release Swimmers by Jessica and it’s employees and owners from any claims, demands and cause of action arising from my child’s participation in this program.”

Please type in your first & last name if you affirm this statement. “I affirm that I have read and understand all the requirements listed above.”

Δ