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 oneInternet SearchFacebookInstagramTwitterYouTubeYelpChamber/Business AssociationEventMother's ClubNewsletterOnline DirectoryPreschool/DaycareReferralSchool

Swimmer 1

Name *

Birthdate *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

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 *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

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 *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

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?

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