Child’s Name __________________________________________________________________________ DOB ________________ Age ________ Gender ________

Parent(s)/Guardian(s) ________________________________________________________________________________________________________________________________________

Home Phone ____________________________________________________________ Cell Phone ___________________________________________________________

Please Choose Group Lessons OR Private Lessons.

At least three people must sign up for a lesson for the lesson to be held. In the event that not enough people sign up, those who have signed up will either be asked to switch times or be given a voucher for a later date. Refunds will not be given except for special circumstances. No refunds will be given for lessons cancelled due to weather or other unforeseen circumstances; a makeup lesson will be scheduled. In the event that a makeup lesson cannot be scheduled prior to the next session starting, a refund will be given or a credit can be applied towards a future session. Refunds for private lessons are not available. In consideration of your acceptance of this entry, I hereby waive, release and forever discard all claims, rights and causes of action of any kind or nature for myself, my heirs, executors and administrators, against sponsors and organizers of the Joplin Family YMCA swim lessons, their agents, servants, officers, employees, directors, representatives and assigns for injury or illness which may directly or indirectly result from my participation in the Joplin Family YMCA swim lessons, and I further agree to save and hold said parties harmless and agree to indemnify each of said persons against all liability for any loss, cost, injury or damage to persons or property which may arise by virtue of the undersigned engaging in the Joplin Family YMCA swim lessons. I further state that I am in proper physical condition to participate in this event. I recognize the sponsors have not undertaken to provide undersigned with any medical care, treatment or advice concerning my participation.

Signature ______________________________________________________________________________________________ Date ___________________________

Return completed and signed form with program fee he Joplin Family YMCA at 3404 W. McIntosh Circle Drive, Joplin, MO 64804.

STAFF USE ONLY

Date ________________ Initials ________________ Amt. Paid ________________

Group Lessons (Eight 45-minute lessons)$50 FOR MEMBERS AND $75 FOR NONMEMBERS

Lesson Level/Time:

Level 1 (M/W4:15 pm) Level 2 (M/W 4:15 pm) Level 3 (M/W 5:15 pm)

Level 1 (T/TH 6:15 pm) Level 2 (T/TH 5:15 pm) Level 3 (T/TH 6:15 pm)

Session:

May 27 – June 20 July 8 – Aug. 1 Aug. 12 – Sept. 5

Sept. 16 – Oct. 10 Oct. 21 – Nov. 14

Private Lessons (Four 45-minute lessons)$80 FOR MEMBERS AND $105 FOR NONMEMBERS

Day(s) of week __________________________________ Time(s) ________________________________ Child’s swimming level ___________________

Instructor preference ___________________________ Comments _______________________________________________________________________________

SAFE SWIMMERS START HERE Swim Lessons Registration JOPLIN FAMILY YMCA

Pick One Session

Group Sessions; 19MAY, 19JUL, 19AUG, 19SEP, 19OCT, 19NOV Private Session: 2019

Level 1 Program Codes: 4:15pm – 02AQL1M/W415 6:15pm – 02AQL1TTH615 Private Program Code: 02AQPRV

Level 2 Program Codes: 4:15pm – 02AQL2M/W415 5:15pm – 02AQL2TTH515

Level 3 Program Codes: 5:15pm – 02AQL3M/W515 6:15pm – 02AQL3TTH615

Pick One Program Code by Level and Time