Roanoke Office  
Jackson River Office  
Pittsylvania Co Office  
Franklin Co Office  

(complete this form and bring to registration)


2010 Winter Learn-to-Swim Registration Form
 
 
Name of participant: _____________________________  Age: ________
 
Address: _____________________________________________________
 
City: ____________ State: __________ Zip: _______
 
Home Number: __________________  Work Number: _________________
(Indicate which is the best place to call: Home or Work)
 
Email address: (required) ________________________________________
(Confirmation will only be sent through email notification)
 
Name of Parent or Guardian: ______________________________________
 
Pool Location: __________________________________________________
 
Session dates: ______________________ Time: ______________________
 
Level enrolling: __________________________________________________


Registration fee of $20 per participant is required at time of registration.

Payment form: __Cash  __Check  __VISA  __AMEX  __MasterCard  __Discover

Card Number: ______________________________   Expiration:_____________

Name on Card: _____________________________________________________

 
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