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(800) 913 - 5633

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Registration At Swim Synergy

Welcome to Swim Synergy! We are thrilled you selected us for your customized swim instruction. Please complete the following registration form. Thank you!

CALL US AT (800) 913 - 5633

Krista, founder, swim synergy

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Registration

REFERRAL INFORMATION

How did you hear about us?

Referral Name

FAMILY INFORMATION

Family Last Name

WHERE DO YOU LIVE?

Home Address

City

State

Zip Code

Primary Phone

ADDITIONAL INFO

Emergency Contact Info

Health Insurance Carrier

CONTACT #1

First Name

Last Name

Type

Home Phone

Work #

Cell #

PORTAL ACCESS
(YOUR EMAIL IS YOUR LOGIN)

Email Address

Confirm Email

Portal Account Password

Confirm Portal Account Password

CONTACT #2

First Name

Last Name

Type

Home Phone

Work #

Cell #

Email Address

Confirm Email

STUDENT #1

Student's First Name

Last Name

Student Gender

Birth Date

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Seizure in the last 12 months?

Was it a febrile seizure?

ADD ANOTHER STUDENT?

Yes

No

STUDENT #2

Student's First Name

Last Name

Student Gender

Birth Date

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Seizure in the last 12 months?

Was it a febrile seizure?

ADD ANOTHER STUDENT 3?

Yes

No

STUDENT #3

Student's First Name

Last Name

Student Gender

Birth Date

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Seizure in the last 12 months?

Was it a febrile seizure?

ADD ANOTHER STUDENT 4?

Yes

No

STUDENT #4

Student's First Name

Last Name

Student Gender

Birth Date

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Seizure in the last 12 months?

Was it a febrile seizure?

ADD ANOTHER STUDENT 5?

Yes

No

STUDENT #5

Student's First Name

Last Name

Student Gender

Birth Date

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Seizure in the last 12 months?

Was it a febrile seizure?

REQUIRED POLICIES

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I AGREE TO ALL OF THE ABOVE

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QUESTIONS OR CONCERNS

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Contact Info

info@swimsynergy.com
(800)-913-5633
Encinitas, CA 92024

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Private Swim Lessons in North County San Diego

TrustLine Registered and Certified CPR & First Aid / American Psychological Association

Private swim lessons for infants, toddlers, children and adults are offered in Encinitas, Carlsbad, (La Costa) / San Elijio Hills, Solana Beach, Del Mar , Oceanside / Vista, Rancho Santa Fe, Carmel Valley and surrounding areas. Adult and children’s In-Home Private Swim Lessons are also offered year round. Please call 800-913-5633 for pricing.

Private swim lessons for infants, toddlers, children and adults are offered in Encinitas, Carlsbad, (La Costa) / San Elijio Hills, Solana Beach, Del Mar , Oceanside / Vista, Rancho Santa Fe, Carmel Valley and surrounding areas. Adult and children’s In-Home Private Swim Lessons are also offered year round. Please call 800-913-5633 for pricing.

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