Fillable Swim Lesson Registration Form - 2015/2016 printable pdf download

YMCA OF BOULDER VALLEY

AFTER SCHOOL SWIM LESSONS

2015-2016 SCHOOL YEAR

Registration: Please turn in non-refundable payment with fall registration packet or with your program site director. Lessons do fill up and space is dependent

on availability of aquatic staff and bus seats.

Transportation: Transportation by a YMCA vehicle is provided to swim lessons to the Mapleton Y (2850 Mapleton Avenue, Boulder, CO 80301). Our staff

accompany the children. Parents will pick up their children between 5:45pm and 6:00pm at the Mapleton Y In the lobby. Photo IDs are required at each pick up

time. Due to safety issues children will not be showering and may not be picked up from the pool or locker rooms.

Please provide plastic bag for suit and towel. All participants must be enrolled to attend the day the lesson occurs. Families registered for drop-in plan must pay

daily drop-in fee for swim lesson days in addition to swim lesson fee as they are in the care of our staff.

Lesson Evaluation: Each lesson is 45 minutes long. On the first day of lessons, each child will be given a “Skills Evaluation.” At that time children will be grouped

with other children of similar ability based on three different skill levels. At the end of the session, each child will receive a skill card with an evaluation of the

swimmer’s skills for the appropriate level.

Fee: $80 per session per child. Includes transportation and lessons with aqautics staff.

Swimmer’s Name____________________________________________________________ School _________________________________________Grade _________ DOB ___________________ Gender: Male

Female

Address ___________________________________________________________________________________________________________________________ City ___________________________________________Zip __________________________

Parent/Guardian Name _____________________________________________________________________________________________ Email __________________________________________________________________________________

Home Phone ____________________________________________________________ Cell Phone ________________________________________________ Work Phone ________________________________________________________

Please check school and sessions you would like to register for.

Mapleton Y

Tuesdays Select school (North Boulder): Whittier

Crestview

Columbine

Foothill

Uni Hill

Flatirons

SESSION A

SESSION B

SESSION C

SESSION D

Sept 15-Oct 20

Oct 27-Dec 8

Jan 26-March 1

March 8 -April 19

Thursdays Select school (South Boulder): Eisenhower

High Peaks/BCSIS

Mesa

Bear Creek

Creekside

SESSION A

SESSION B

SESSION C

SESSION D

Sept 17-Oct 22

Oct 29-Dec 10

Jan 28-March 3

March 10-April 21

YMCA Financial Assistance pays same percentage as authorized for School Age Care. CCAP Parents pay $30 per session.

Please list any medical conditions or allergies your child has: _____________________________________________________________________________________________________________________________________

Waiver: My child is in good health and is capable of participating in YMCA swimming lessons. I understand the potential risks of participation and hold harmless

the YMCA, staff, directors and volunteers from accidents resulting from participation. I authorize, in a medical emergency, after reasonable effort has been made

to notify parents, that a YMCA representative may seek emergency assistance at the parent/guardian’s expense. Parents will pick up their children between

5:45pm and 6:00pm at the Mapleton Y. Photo IDs are required at each pick up time. Due to safety issues children will not be showering and may not be picked up

from the pool or locker rooms.

Payment Method: Check# __________________________________________________________________________________________OR Credit/Debit (check one) VISA

AMEX

DISC

Name on Card _______________________________________________________________________________________________________ Card# __________________________________________________________________________________

Exp __________________________ VCODE _________________ Signature ____________________________________________________________________________________________________ Date _________________________________

Parent/Guardian Signature _________________________________________________________________________________________________________________________________________________________________________________

Internal Use Only

Registered at: Mapleton Y

Arapahoe Y

Program Site: _____________________________________________________________________________________________________________________________________

Intake Name ___________________________________________________________________________________________________________Date __________________________________________________________________________________

Registration Specialist _____________________________________________ Date _______________________________ Billing Name ______________________________________________ Date _____________________________

Swim Lesson Registration Form - 2015/2016

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