Registration Status: *

• New Family
• Returning Family

Name *

First

Last

Daytime Phone

Evening Phone

Cell Phone *

Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Email *

Email

Confirm Email

At which American Swim Academy location would you like to schedule lessons? *Select LocationFremontNewarkLivermoreDublinWalnut Creek

How did you hear about us? *Please select oneReferralSocial MediaEventGoogleGroupon

Swimmer 1

Name *

Birthdate *

Gender *

• Male
• Female

Program: *

• Infant/Toddler
• Pre-Schooler
• Beginning
• Intermediate/Adv.
• Young Adult
• Adult

Is there any additional information about this student you would like to share with us?

Swimmer 2

Do you have a second swimmer to register? *

• Yes
• No

Name of Swimmer 2 *

Birthdate *

Gender *

• Male
• Female

Program: *

• Infant/Toddler
• Pre-Schooler
• Beginning
• Intermediate/Adv.
• Young Adult
• Adult

Is there any additional information about this student you would like to share with us?

Swimmer 3

Do you have a third swimmer to register? *

• Yes
• No

Name of Swimmer 3 *

Birthdate *

Gender *

• Male
• Female

Program: *

• Infant/Toddler
• Pre-Schooler
• Beginning
• Intermediate/Adv.
• Young Adult
• Adult

Is there any additional information about this student you would like to share with us?

Phone

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