Coes Pond Swim Lessons- Registration-English Version

YWCA is offering FREE water safety and swim lessons for children and youth ages 6-16 years old that live in the Main South/Coes Pond Community!

"*" indicates required fields

Child's Name*
Parent/Guardian Name*
Prefer Session Timeslot:*
Pick one (time of session will be confirmed by Aquatics Director)

Emergency Contact and Medical Info

Emergency Medical Release*
Please check box to agree
Physician Information*
Physician's Name
Hospital Affiliation
Physician Address*
Medical Information*
Medical Insurance Provider
Policy and/or Group Number
Medical Conditions (Please check all that apply)*
Medical Release*

Demographic Information

Please choose the appropriate selection for your family:
Household Income*
Race of Child*
Ethnicity of Child*
What language do you primarily speak at home?*
Chose one:
Source of Income:*
Housing Status*
Total Number Living in Household:*
Type of School (Child)*