Participant Name(*) Please let us know your name. Participant DOB(*) Invalid Input Parent-Guardian Name(*) Invalid Input Cell Phone(*) Invalid Input Email(*) Invalid Input Street Address(*) Invalid Input City(*) Invalid Input State(*) Invalid Input Zip Code(*) Invalid Input Are you a Kingsbury Club Member?(*) Yes No Invalid Input Choose one of the following that best describes the participant(*) Am 3 years old at the start of the program. Can separate from parent and follow instructor directions Can glide with face underwater 3 yards and is beginning to swim independently using arms, not touching the bottom Can swim face-in freestyle (crawlstroke) with arms coming out of the water; and swim across the pool without assistance Can proficiently swim freestyle, backstroke, and breaststroke; and swim 50 yards of both freestyle and backstroke Invalid Input Please provide specific earliest and latest lesson starting time for each day you can be at the pool. (For example: Mondays, 8 - 10 AM and 2 - 4 PM)(*) Invalid Input Other Comments (special needs, health concerns, etc.) Invalid Input Terms(*) PLEASE READ TERMS&CONDITIONS HERE Invalid Input Send
