registration - flipfloatswim

Give the gift
of water safety

A life-saving skill starts here! Personalized, one-on-one swim lessons for infants and toddlers.

Registration Form

Child's full name

Age in months

Date of birth

Gender

Weight at birth

Length at birth

Current weight

At what age did this child (sit unassisted, Crawl, Walk 3 feet alone (all in months))

Primary Contact

Secondary Contact

Mailing Address

City

State

Zip

Home Phone

Mobile Phone

email address

Pediatrician's Name

Pediatrician's Phone #

Select if YES

Has this child been evaluated for or diagnosed with a genetic or developmental condition? Does this child have a chronic medical condition? Has this child ever lost consciousness? Has this child ever required CPR? Has this child ever suffered a seizure or other abnormal neurological event? Has this child ever had a breath-holding or fainting episode? Has this child ever had a kidney or bladder infection? Has this child ever seen a medical specialist? Is this child currently seeing a therapist? Is this child currently taking any prescription or over-the-counter or homeopathic remedies? Is this child currently prescribed an EpiPen or an autoinjector for severe allergic reactions? Has this child experienced recurrent respiratory problems? Has this child had any surgeries, apart from hypospadias correction or ear tube placement? Has this child ever ever been hospitalized? Has this child ever been treated in the Emergency Room? Were there complications during pregnancy/delivery?

Please describe any previous swimming lessons or water related activities this child has participated in, and when.

How have you interacted with this child in and around the water prior to these lessons?

Sent $240 via Venmo to @Sandra-Koury-1 ($200 for last week of lessons + $40 registration).

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