Swim Lesson Registration Form - 2017
PARTICIPANT'S NAME:
FAC MEMBER
JUNIOR MEMBER
PARTICIPANT'S SWIM EXPERIENCE:
R
NON-MEMBER
SOME SWIMMING WILL PLACE HEAD
UNDER WATER
BEGINNER
Participant's Street Address
DATE OF BIRTH: (children only)
SWIM TEAM AND/OR NEEDS
STROKE IMPROVEMENT ONLY
ADVANCED
INTERMEDIATE
City:
State:
Zip:
Primary Caregiver Name:
Email:
Relationship
Cell phone:
Work phone:
Secondary Caregiver Name:
Email:
Relationship
Cell phone:
Work phone:
Emergency Contact Name:
Email:
Relationship
Cell phone:
Work phone:
Medical Emergency Information
Epi-Pen/ Epinephrine
Antihistamine
Please
R
all that apply
Rescue Inhaler
Diabetic Insulin
Other: (please specify)
GROUP SWIM LESSONS
GROUP LESSONS AGES 2 - 4 YEARS
R
GROUP LESSONS AGES 2 - 4 YEARS
R
GROUP LESSONS AGES 5-12 YEARS
R
GROUP LESSONS AGES 5-12 YEARS
R
CHECK LEVEL AND PREFERRED TIME
STARFISH (BEGINNER)
9:00 AM
STARFISH (BEGINNER)
10:00 AM
STARFISH (BEGINNER)
11:00 AM
STARFISH (BEGINNER)
4:00 PM
CHECK LEVEL AND PREFERRED TIME
CLOWNFISH (INTERMEDIATE)
9:00 AM
CLOWNFISH (INTERMEDIATE)
10:00 AM
CLOWNFISH (INTERMEDIATE)
11:00 AM
CLOWNFISH (INTERMEDIATE)
4:00 PM
STINGRAY (BEGINNER)
9:30 AM
STINGRAY (BEGINNER)
10:30 AM
STINGRAY (BEGINNER)
11:30 AM
STINGRAY (BEGINNER)
4:30 PM
DOLPHIN (INTERMEDIATE)
9:30 AM
DOLPHIN (INTERMEDIATE)
10:30 AM
DOLPHIN (INTERMEDIATE)
11:30 AM
DOLPHIN (INTERMEDIATE)
4:30 PM
CHECK LEVEL AND PREFERRED TIME
CHECK LEVEL AND PREFERRED TIME
PLEASE NOTE: DUE TO THE FAST PACED SCHEDULE OF SUMMER CAMP, SUMMER CAMPERS WILL NOT BE PERMITTED TO ATTEND ANY MORNING CLASSES
GROUP LESSONS - MONDAY - THURSDAY (INCLEMENT WEATHER MAKE-UP - FRIDAY) PRICES LISTED BELOW INCLUDE 4 GROUP LESSONS IN ONE WEEK.
JUNE 5 - 9, 2017
MEMBER $65
NON-MEMBER $75
JUNE 12-16, 2017
MEMBER $65
NON-MEMBER $75
JUNE 19-23, 2017
MEMBER $65
NON-MEMBER $75
JUNE 26-30, 2017
MEMBER $65
NON-MEMBER $75
(M, W, TH, F - no class July 4th)
MEMBER $65
NON-MEMBER $75
JULY 10-14, 2017
MEMBER $65
NON-MEMBER $75
JULY 17-21, 2017
MEMBER $65
NON-MEMBER $75
JULY 24-28, 2017
MEMBER $65
NON-MEMBER $75
JULY 31 - AUGUST 4, 2017
MEMBER $65
NON-MEMBER $75
AUGUST 7 - 11, 2017
MEMBER $65
NON-MEMBER $75
JULY 3-7, 2017
PRIVATE AND SEMI-PRIVATE LESSONS
NAME OF 2ND SWIMMER IN SEMI-PRIVATE:
CIRCLE PREFERRED DAY(S)
MON TUE WED THU FRI SAT SUN
PRIVATE LESSON
R
SEMI-PRIVATE LESSON
CIRCLE PREFERRED DAY(S)
MON TUE WED THU FRI SAT SUN
PRIVATE AND SEMI PRIVATE LESSONS
CIRCLE PREFERRED TIME OF DAY: MORNING AFTERNOON EVENING
PREFERRED START DATE FOR LESSONS:
HOW MANY DAYS PER WEEK DO YOU WANT TO
ATTEND PRIVATES OR
SEMIPRIVATES?
SHARKS GEAR
IF MORE THAN ONE DAY PER WEEK, WHAT ARE Are you training for a specific event? If so, what is the event and date? Event name/date:
YOUR PREFERRED DAYS?
DIAPER DOLPHINS
FAC Sharks will be participating in swim meets Diaper Dolphins meet every Saturday morning at 9:00 AM in the family
this summer. If you would like to sport your FAC pool. This is a parent/child class where we ask all parents to be in the
water with your child throughout the class
Sharks colors, shirts and caps are listed below.
FAC SHARKS SWIM TEAM SHIRT
FAC SHARKS SWIM TEAM CAP
CIRCLE PREFERRED TIME OF DAY: MORNING AFTERNOON EVENING
$12 EACH
$8 EACH
SHARKS SWIM TEAM
Sharks Swim Team practices Monday/ Wednesday 10:00 - 11:00 AM, 5:30 - 6:30 PM AND Tuesday/ Thursday 5:30 7:00 PM. FAC Sharks may attend up to 6 practices per week. The monthly fee includes all practices within the
month. Event fees for swim meets are not included. Campers will not attend morning practices
JUNE - NON-MEMBE $75 PER MTH
JUNE 2017 MEMBER
$65 PER PERSON/ PER MONTH
JUNE 2017 NON-MEMBER
$80 PER PERSON/PER MONTH
JULY - MEMBER $65 PER MTH
JULY - NON-MEMBE $75 PER MTH
JULY 2017 MEMBER
$65 PER PERSON/ PER MONTH
JULY 2017 NON-MEMBER
$80 PER PERSON/PER MONTH
AUG - MEMBER $65 PER MTH
AUG - NON-MEMBE $75 PER MTH
AUGUST 2017 MEMBER
$35 PER PERSON (1/2 MONTH)
AUGUST 2017 MEMBER
$45 PER PERSON (1/2 MONTH)
JUNE - MEMBER $65 PER MTH
SIBLING DISCOUNT $5 PER CHILD FOR THE 2nd, 3rd, 4th and 5th children In the same family. May not be combined with any other discounts.
METHOD OF PAYMENT:
MASTERCARD VISA AMEX DISCOVER (CIRCLE ONE)
CHECK ATTACHED
CARD #
Expiration date:
Check #
Cash: $
I agree to assume full risk and release all claims I and/or the participants may have against the Fayetteville Athletic Club (FAC), including it's agents, servants and employees, from such claims resulting from injury, damages or loss sustained
during participation in any FAC off site parent program or event. I understand that I am responsible for all personal medical insurance and the participant's family must cover any cost incurred. I also understand that every precaution is
taken to protect the safety of all participants. I agree to any emergency treatment by a physician or hospital in the event that the emergency contact listed above can not be reached.
Signature of Parent or Guardian OR participant if 18 years or older:
Date:
FOR INTERNAL USE ONLY: INSTRUCTOR/COACH ASSIGNED TO:
Date: