Water Safety Patrol Swimming Lesson Registration Form

Participant’s Name:______Age:______

Parent’s Name______

(if participant is under 18 years old)

Address: ______


______Phone:______

Program Desired: Twice Per Week Once Per Week

Level of Lesson Desired:

Parent/Toddler (min. age 1)

Beginner 1 (min. age 3)

q  Beginner 2

q  Beginner 3

Advanced Beginner

q  Intermediate

q  Swimmer

Advanced Swimmer

Water Masters (min. age 11)

Lifeguard Training (min. age 15)

Water Aerobics (adults)

Location of Lesson Desired:

Lake Geneva (Riviera)

q  Williams Bay

q  Fontana

q  Linn Pier

q  Knollwood

q  Buena Vista

Robinson Hillside

Signature Required:

I (the undersigned) authorize the above named individual (the participant) to participate in the Geneva Lake Water Safety Patrol Swimming Lesson Program. I assume all risks and hold harmless the Geneva Lake Water Safety Patrol and all of its instructors and employees in the event of an accident or injury.

Signature of parent or authorized adult:______

Print name:______date:______

For office use only (do not write in this box)

Participant Name:______

Level:______Days:______

Lesson Time:______Location:______

Instructor:______