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Linden Aquatics
Swim Lesson Registration Form
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Email
*
Your email
Are you registering for:
*
Swim Lessons
Stroke Camps
Water Aerobics
Kids Night Out
Masters
1st Child's Name and Age:
Your answer
2nd Child's Name and Age:
Your answer
3rd Child's Name and Age:
Your answer
4th Child's Name and Age:
Your answer
Are you a returning family to Linden Aquatics?
Yes
No
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Address, City, Zip:
Your answer
Mother’s Name:
Your answer
Mother's Phone #
Your answer
Father's Name
Your answer
Father’s Phone #
Your answer
Emergency Contact (other than Parents ):
Your answer
Emergency Contact Relationship:
Your answer
Emergency Contact Phone Number:
Your answer
Medical Insurance Company:
Your answer
Policy Number:
Your answer
Please list any limitations and/or cautions we should be aware of in case of a medical emergency, (ie. allergies, illness, etc.).
Your answer
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