Ford Pool

Learn to Swim Registration Form

Prices for the sessions are as follows:

$35.00 per session First Time Swimmers
$30.00 per session Additional Training

Any questions? For more information contact Joey Sutherlin, Aquatics Director via email at jsutherl@grcc.edu or phone at 616 234 4266.

* Required Fields

Personal Information

First Name: *
Last Name: *
Email: *
Phone: *
Cell Phone
Date of Birth

Address

Address
City
State
Zip

School Information

School
Grade Level
Coach's Name

T-shirt Size

Small
Medium
Large
X-Large

Parent or Guardian Information

Father/Guardian

First Name: *
Last Name: *
Email
Phone: *
Cell Phone

Mother/Guardian

First Name: *
Last Name: *
Email
Phone: *
Cell Phone

Emergency Contact

Other than immediate family member.

First Name: *
Last Name: *
Phone: *
Cell Phone

Medical Information

Insurance Provider: *
Policy Number: *

Are there any health problems that the coaching staff should be aware of ?

Yes
No

If yes, please list them here:

Classes

Levels 1-3

For children aged 5-11

Session A	Sep 10 - 13 & 17 - 20	M - Th	4:35 pm - 5:15 pm
Session B	Oct 1, 3, 8, 10, 15, 17, 22, 24	M W	4:35 pm - 5:15 pm
Session C	Oct 2, 4, 9, 11, 16, 18, 23, 25	T Th	4:35 pm - 5:15 pm
Session D	Nov 5 - 8 & 12 - 15	M - Th	4:35 pm - 5:15 pm
Session E	Dec 3 - 6 & 10 - 13	M - Th	4:35 pm - 5:15 pm
Session F	Jan 7, 9, 14, 16, 21, 23, 28, 30	M W	4:35 pm - 5:15 pm
Session G	Jan 8, 10, 15, 17, 22, 24, 29, 31	T Th	4:35 pm - 5:15 pm

Levels 4-6

For children aged 9 and up

Session 1	Sep 7, 14, 21, 28	Fri	4:35 pm - 5:55 pm
Session 2	Oct 5, 12, 19, 26	Fri	4:35 pm - 5:55 pm
Session 3	Feb 1, 8, 15, 22	Fri	4:35 pm - 5:55 pm
Session 4	Mar 7, 14, 21, 28	Fri	4:35 pm - 5:55 pm
Session 5	Oct 6, 13, 20, 27	Sat	10:35 am - 11:55 am
Session 6	Feb 2, 9, 16, 23	Sat	10:35 am - 11:55 am
Session 8	May 3, 10, 17, 31	Sat	10:35 am - 11:55 am

Confirmation

I certify that the information contained in this registration form is complete and true to the best of my knowledge and ability. I hereby hold Grand Rapids Community College harmless with respect to any injury, accident, medical or dental expense, or any other claim that could or might arise as a result of participation in the Gator Swim Program, be it at the facilities of the Grand Rapids Community College Ford Natatorium, or at other facilities. In the event of an injury or other medical emergency, full consent is hereby given for the initial on-site treatment, medical transport, and hospital emergency room care to be administered until such time as a parent or guardian can be located. The extent of steps taken or treatment provided will be determined by the nature of the emergency and evaluation of medical staff.

: I confirm that all the information submitted here is accurate

10523 page hits and 9876 unique visits since 06-05-02
Updated on 25-FEB-08
Edit this page | View text only version

Grand Rapids Community College

Menu

Ford Pool

Learn to Swim Registration Form