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Youth Program
Power Clinic Registration
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Parent/Guardian Name
*
First
Last
Phone
*
consent Birth Name
Email
*
Emergency Phone Numbers (if different from Prent)
Swimmer's Name
*
First
Last
Date of Birth
*
mm/dd/yyyy
Gender
*
--- Select Choice ---
Male
Female
Other
Current Skill Level:
Afraid of water/Will not put face in
Comfortable in water but cannot float alone
Can float on back/front but cannot swim
Can swim 5+ meters independently
N/A
Other
Medical Conditions/Allergies
Asthma
Ear sensitivity
Skin Sensitivity (chlorine)
N/A
Other
Learning/Physical Needs:
Very important for our instructors to know if a child has ADHD, sensory processing needs, or physical disabilities that require extra attention
Select Clinic Session
*
1 Week -
$800.00
Any 2 weeks -
$1,575.00
Any 3 weeks -
$2,350.00
Any 4 weeks -
$3,125.00
Any 5 weeks -
$3,900.00
Any 6 weeks -
$4,675.00
All 7 weeks -
$5,450.00
Please note: If the remaining balance is not paid in full by the required deadline, the participant’s registration will be canceled, the reserved spot will be released to a swimmer on the waiting list, and all payments made toward the session, including any partial or deposit payments, will be forfeited and are not eligible for a refund or credit
Credit/debit Card
*
Card
Name on Card
Coupon
Apply
Total
Order Summary
Item
Quantity
Qty
Total
There are no products selected.
Select Clinic Session - 1 Week
1
$800.00
Select Clinic Session - Any 2 weeks
1
$1,575.00
Select Clinic Session - Any 3 weeks
1
$2,350.00
Select Clinic Session - Any 4 weeks
1
$3,125.00
Select Clinic Session - Any 5 weeks
1
$3,900.00
Select Clinic Session - Any 6 weeks
1
$4,675.00
Select Clinic Session - All 7 weeks
1
$5,450.00
Subtotal
Total
$0.00
$0.00
Media Use Consent & Release
*
Yes, I opt in. I authorize the use of my student's image and likeness as described
No, I opt out. I request that my student's image or likeness not be used
Please read the following information regarding the use of photography, audio, and video recording during our swim sessions. By opting in, you allow Elite Swim Academy to use photographs, video footage, or audio recordings featuring your student for promotional materials, social media, our website, and future marketing campaigns. We promise to always use these materials respectfully and professionally.
I consent
to the Terms & Conditions
Register
