Survival Swim Lesson Registration | Specialized Infant Aquatics Tucson, AZ

Name

Initial

Age (Year & Month)

Date

Address

City

Zip

Mother's Name

Occupation

Phone (Home)

Phone (Cell)

Email address*

Father's Name

Occupation

Phone (Home)

Phone (Cell)

Email address*

Gender

Birth Weight

Height

Current Medication

Pregnancy or Delivery Problems

Full Term

Premature

Weeks Premature

ICU

Oxygen Needed

Developmental Milestones

Sit Alone (mos)

Crawl

Stand Alone

Walk

Pediatrician's name and number

Please answer the following: (Check if Yes) If you answer yes, please explain below:

Explanation of any Yes

Family Has or Vacations Near:

Pool

Hot Tub

Pond

Lake

Canal

Boat

Ocean

River

Other

Previous aquatic instruction, if any:

Program Type

Where

When

Are all family members aquatically skilled

Has your child ever had an aquatic accident or incident

If yes, please explain

Has your child ever used a floatation device

Type of device?

How long used?

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REGISTRATION