swim programs registration form - The Medical University of South

SPRING 2014 YOUTH SWIM PROGRAMS REGISTRATION FORM
PROGRAM: please circle- Group Swim Lessons, Aquatots, Tadpoles, Swim Club, Youth Stroke Clinic, Private Swim Lesson
(Private Swim Instructor’s Name:____________________________), other:______________________________
CHILD’S NAME: First name, Last name
Age
List any relevant medical information (allergies, medications, and special needs – use reverse side if necessary)
_________________________________________________________________________________________
Parent(s) Names and contact information:
_______________________________________/___________________/____________________/__________________
First Name
Last Name
home phone
work phone
cell phone
Additional emergency contact:
_____________________________________/____________________/___________________/____________________
First Name
Last Name
home phone
work phone
cell phone
Email Address:
Group swim classes meet 1X/week with a total of 6 classes offered over a 6 week session. Prices are per session. Private lessons are ongoing.
*Wellness Center Member rates/Nonmember rates
Wellness Center Member? (Please circle) YES or NO
PAYMENTS:
Credit Card ___________
or
If so, provide name and member #:__________________
Check (payable to MUSC Wellness Center) __________
I am paying the amount of $ ________________ for _________________________ (type of swim class or private lessons).
Credit Card #
EXPIRATION: month/year
FAX: 843-792-7933
PHONE: 843-792-0767
EMAIL: [email protected]
MAILING ADDRESS: MUSC WELLNESS CENTER
ATTENTION: Wendy Williams, Suite 232
45 Courtenay Drive
MSC 176
Charleston, SC 29425-1760
WAIVER
In consideration of your accepting my registration, I hereby, for myself, my child, my heirs, executors and administrators, waiver and
release any and all rights and claims for damages I or my child may have against the Medical University of South Carolina and its
representatives, successors and assigns for any and all injuries suffered by myself or my child at any activity sponsored by these
groups. I understand that I am encouraged to maintain proper insurance coverage for my child during the duration of his/her
participation and specified activities with this institution. I hereby certify all the above information to be correct and true.
SIGNATURE OF PARENT OR GUARDIAN:
_______________________________________________________________ DATE:__________________
Child’s Name:_____________
Date:_____________
MUSC GROUP SWIM PROGRAM REGISTRATION FORM SPRING 2014
Spring Session: Sunday, March 2 to Saturday, April 12 (6 weeks)
Registration for Spring 2014 Swim Session opens February 16 and closes February 27.
Registration opens February 16, 2014. In order to enroll, please submit a completed registration form along with payment. You will receive an
email within 5 business days confirming class level, time and day. Enrollment in spring session does not guarantee class enrollment in spring minisession. Registration for the 4 week spring mini-session (April 27 to May 24) opens April 13, 2014. Space is limited!
Registration Details for Group Swim Lessons: Please circle the appropriate session, day and the level/class time. You may indicate a 1st
nd
choice and a 2 class choice. Group classes must have a minimum of at least 3 participants in order to be offered.
Additional Information: Preschool Classes: max 4 participants, Beginner Classes: max 5 participants, Swimmer Classes: max 6 participants and
Youth Stroke Clinic: max 6 participants. We absolutely cannot allow drop in participation. Please bring your own towel and refrain from using the
nd
adult locker rooms. Family restrooms are located down 2 hallway by Bee St.
No free swim before or after class. Children are only allowed in the pool accompanied by their swim instructor.
**We do not offer make-up classes or price adjustments for missed classes.**
Spring Session Sunday, March 2 to Saturday, April 12 (6 weeks)
Circle appropriate below class level, time and day you wish to enroll your child.
Group Swim Lesson Cost: $75/MUSC Wellness Center Member & $90/Nonmember for a 6 week session
Note: Prices reflect one class per week with a total of 6 classes offered. We are not able to offer make-up classes.
Please circle appropriate day of week, class time and level.
Group Swim
Lesson Cost
$75/$90*
(25 minutes in
length per lesson)
Sunday
Monday
Tuesday
Wednesday
Thursday
Saturday
Spring Session
Spring Session
Spring Session
Spring Session
Spring Session
Spring Session
Class Dates:
March 2, 9, 16,
23, 30 and
April 6
Class Dates:
March 3, 10, 17,
24, 31 and
April 7
Class Dates:
March 4, 11, 18, 25
April 1 and 8
Class Dates:
March 5, 12, 19, 26
April 2 and 9
Class Dates:
March 6, 13, 20, 27,
April 3 and 10
Class Dates:
March 8, 15, 22, 29
April 5 and 12
9:05 to 9:30 am
9:30 to 9:55 am
10:00 to 10:25 am
10:30 to 10:55 am
11:00 to 11:25 am
3:00 to 3:25 pm
3:30 to 3:55 pm
4:00 to 4:25 pm
4:30 to 4:55 pm
5:00 to 5:25 pm
Preschool 1
9:15-9:40
Tadpoles
Preschool 1
Swimmer
Preschool 2
Beginner 2
Beginner 1
Beginner 1
Preschool 2
Preschool 2
*Wellness Center member rates/nonmember rates
Swimmer 1
Preschool
Preschool 1
Swimmer
Beginner 1
Preschool 2
Preschool 2
Beginner 2
Preschool 1
Beginner 2
Specialty Classes & Private Swim Lessons
Please circle below appropriate class, and day/time. Aquatots & YSC follow the same session dates as group classes.
Aquatots
$50/$60*
for the 6 week session
Youth Stroke Clinic (YSC)
$120/$150*
for the 6 week session
(25 minutes in length per lesson)
(20 minutes in length per lesson)
Saturday 9:30 to 9:50 am
or
Saturday 11:00 to 11:20 am
(circle one day and time)
Private & Semi-Private Swim Lessons
Private and semi-private lessons are on-going.
E-mail our Private Swim Coordinator
([email protected]) to request a Private Swim Request
Form and Policy Sheet.
4 private lesson package $120/$160*
4 semi-private (2 participants) lesson package
$150/$190*
($75/$95* per swimmer for semi-private lessons)
Phone: 843-792-0767 E-mail: [email protected] Fax: 843-792-7933
www.musc.edu/hsc
(50 minutes in length per lesson)
Thursday 4:00 to 4:50 pm
or
Saturday 11:00 to 11:50 am
(circle one day and time)

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