Registration – Aquatics Locomotion

Name *

First

Last

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

I am signing up for the following session

Oct. 20 – Nov. 12

I have read the liability waiver on the program description link and agree to this contract. *

Agree

attend month. Email

I understand that to qualify for reimbursment, I must attend at least 5–6 classes during the month. *

Birthday month and day only