Baby's Name *

First Name

Last Name

Baby's date of birth *

Enter DAY, MONTH, YEAR of birth

MM

DD

YYYY

Baby's sex *

Male

Female

Main contact *

Mother

Father

Mother's Name

First Name

Last Name

Father's Name

First Name

Last Name

Was your baby caesarean birth? *

Yes

No

Was your baby premature? *

Yes

No

Does the person attending the class with the child, suffer from any of the following health conditions?

Diabetes

Heart problems

Asthma

Epilepsy

Back or neck problems

Other

Do we have your permission to use photographs of you & your baby on our website and or in printed promotional material? *

Yes

No

I would like to receive information about children's classes & Aqua Vie news by email *

Yes

No

I would like to receive information about adult classes & Aqua Vie news by email *

Yes

No

I agree to inform the teacher of any changes or additions to the above information at the beginning of the class. *

I agree

I understand that I will be responsible for my child at all times. *

I Agree

Terms and conditions *

I have read and accept the terms and conditions

Today's date *

Enter DAY, MONTH, YEAR as today's date

MM

DD

YYYY