swim questionnaire swim ability
SWIM QUESTIONNAIRE Please Check Your Childs Current Swimming Capability
_____________________________________, __________________________________ First Last Has your child had swim lessons before? Yes ___,Where? ________________ What is your child’s attitude toward water?
No ___
Positive ___ Negative ___
Will your child place his/her head under the water? Yes ___ No ___ Does your child Jump &/or Dive from the... Side of the pool J__D__ Diving board J__D__ Does your child dive from the...
Side of the pool ___ Diving board ___
Can your child...
Dog paddle
Does your child swim:
___ Swim under water ___
Freestyle___ (Side Breathing Y__ N__) Elem. Backstroke ___ Backstroke___ Breaststroke (Proper Breathing__ Head up__ Head-down__) Butterfly___ Starting Block Dive___ Flip Turns___
Competitive-Style: 50 Fly__ 50 Back__ 50 Breast__ 50 Free__ 100 IM__ (Individual Medley)
***Please Attach Any Medical Information That Would Be Helpful To Your Child’s Instructor Including Medical Issues, Special Needs, Personality Type, Adjustment To New Situations, Etc...
SWIM ABILITY Check The One That Best Describes Your Child
SUMMER CAMP ___ Beginner - Learning Primary Skills: - Needs support if water is over their head ___ Adv. Beginner - Stroke Readiness: - 2-widths of the pool with face in & out, w/out support ___ Intermediate - Stroke Development - 1-length of the pool with face in & out, w/out support ___ Intermediate Advanced - Stroke Refinement ___ Advanced - Swimming and Skill Refinement
WESLEYAN EDUCATION CENTER 1917 N. Centennial St., High Point, NC 27262 [email protected] • (336) 884-3333 Ext. 228 http://www.wesed.org/Page/Athletics/Aquatics/Aquatics-Offerings
SUMMER CAMP SWIM REGISTRATION
MULTIPLE SESSION DISCOUNT: Register for 2 Sessions per Child
MAKE CHECKS PAYABLE TO:
Receive $10 Discount
One Check per Child PLEASE
Wesleyan Aquatics
(Wesleyan Aquatics = 10 classes per Session / Piedmont –area programs = 8 classes per Session)
SWIM DATES Kindergarten
June 20-July 1
1st—6th Grades
July 11-July 22
Kindergarten
July 25-Aug 5
__ _ ___
_______________________________ Emergency Contact Name
______________________________ Relationship to Child
_______________________________ Home / Cell
______________________________ Email Address
_________________________________________________________________ Home Address (Street / City / St / Zip) _________________________________________________________________ Summer Camp Grade & Teacher’s Name
CHOOSE YOUR SWIM DATES
__ _
__ _
__________________________________________________________________ Child’s Name (First / MI / Last)
Please retain this information for your records
SESSION ONE: __June 6-17, 2016 Kindergarten
Please Retain This Information For Your Records
SESSION TWO: __July 11-22, 2016 Kindergarten
__June 20-July 1, 2016 Grades 1st - 6th
__July 25-Aug 5, 2016 Grades 1st - 6th
Please See Summer Camp Teacher For Specific Swim Lesson Times
RELEASE AND WAIVER OF LEGAL LIABILITY As parent/guardian of the above camper, I certify that he/she is in excellent health and has no physical, mental or emotional problems, which are likely to prevent participation in camp. I agree to hold harmless Wesleyan Education Center and its agents, employees, counselors and volunteers. I hereby release them from any liability on account of injuries sustained by camper while participating in camp activities. I give permission for camper to be medically treated for illness occurring or injury sustained during such participation and certify that he/she is covered by medical insurance which will reimburse the aforementioned Wesleyan Education Center for medical treatment ordered at their discretion and also to indemnity them for any expenses not reimbursed by such insurance. I have read the above: _________________________________________
________________
Parent’s Signature
Date Signed
1st—6th Grades
-OFFICE USE ONLY-
_ __
June 6-June 17
___ __ _ ___ __ _ C ut H er e an d R et u rn w i t h P ay me nt
PAYMENT & BILLING INFORMATION $75 per session
___
FEATURED ACTIVITIES: Skills Competency • Competition • Survival Skills Recreation Snorkeling • Water Basketball • Water Polo • Games
___
• Beginner to advanced classes available • Testing upon entry to ensure proper class placement • Smooth transitions between instructional levels • Self-paced advancement
___
As an active participant in our American Red Cross swimming program, your student will learn, develop, and refine their swimming skills, water safety, boating safety, and personal flotation device usage. In addition, Wesleyan Aquatics offers the following advantages:
___
Wesleyan Aquatics has been teaching swimming skills and water confidence to children for more than 30 years. We engage in a firm but gentle teaching approach, instilling joy and respect for God’s awesome creation of water. Our low student-teacher ratios allow our students to receive individual attention while benefiting from small, organized group sessions.
_ __
ABOUT WESLEYAN AQUATICS
Ck No: _________
Ck Amt: ____________
Cash Amt:: _______________
Staff Initials: ______________
_____________________________________, __________________________________ First Last Has your child had swim lessons before? Yes ___,Where? ________________ What is your child’s attitude toward water?
No ___
Positive ___ Negative ___
Will your child place his/her head under the water? Yes ___ No ___ Does your child Jump &/or Dive from the... Side of the pool J__D__ Diving board J__D__ Does your child dive from the...
Side of the pool ___ Diving board ___
Can your child...
Dog paddle
Does your child swim:
___ Swim under water ___
Freestyle___ (Side Breathing Y__ N__) Elem. Backstroke ___ Backstroke___ Breaststroke (Proper Breathing__ Head up__ Head-down__) Butterfly___ Starting Block Dive___ Flip Turns___
Competitive-Style: 50 Fly__ 50 Back__ 50 Breast__ 50 Free__ 100 IM__ (Individual Medley)
***Please Attach Any Medical Information That Would Be Helpful To Your Child’s Instructor Including Medical Issues, Special Needs, Personality Type, Adjustment To New Situations, Etc...
SWIM ABILITY Check The One That Best Describes Your Child
SUMMER CAMP ___ Beginner - Learning Primary Skills: - Needs support if water is over their head ___ Adv. Beginner - Stroke Readiness: - 2-widths of the pool with face in & out, w/out support ___ Intermediate - Stroke Development - 1-length of the pool with face in & out, w/out support ___ Intermediate Advanced - Stroke Refinement ___ Advanced - Swimming and Skill Refinement
WESLEYAN EDUCATION CENTER 1917 N. Centennial St., High Point, NC 27262 [email protected] • (336) 884-3333 Ext. 228 http://www.wesed.org/Page/Athletics/Aquatics/Aquatics-Offerings
SUMMER CAMP SWIM REGISTRATION
MULTIPLE SESSION DISCOUNT: Register for 2 Sessions per Child
MAKE CHECKS PAYABLE TO:
Receive $10 Discount
One Check per Child PLEASE
Wesleyan Aquatics
(Wesleyan Aquatics = 10 classes per Session / Piedmont –area programs = 8 classes per Session)
SWIM DATES Kindergarten
June 20-July 1
1st—6th Grades
July 11-July 22
Kindergarten
July 25-Aug 5
__ _ ___
_______________________________ Emergency Contact Name
______________________________ Relationship to Child
_______________________________ Home / Cell
______________________________ Email Address
_________________________________________________________________ Home Address (Street / City / St / Zip) _________________________________________________________________ Summer Camp Grade & Teacher’s Name
CHOOSE YOUR SWIM DATES
__ _
__ _
__________________________________________________________________ Child’s Name (First / MI / Last)
Please retain this information for your records
SESSION ONE: __June 6-17, 2016 Kindergarten
Please Retain This Information For Your Records
SESSION TWO: __July 11-22, 2016 Kindergarten
__June 20-July 1, 2016 Grades 1st - 6th
__July 25-Aug 5, 2016 Grades 1st - 6th
Please See Summer Camp Teacher For Specific Swim Lesson Times
RELEASE AND WAIVER OF LEGAL LIABILITY As parent/guardian of the above camper, I certify that he/she is in excellent health and has no physical, mental or emotional problems, which are likely to prevent participation in camp. I agree to hold harmless Wesleyan Education Center and its agents, employees, counselors and volunteers. I hereby release them from any liability on account of injuries sustained by camper while participating in camp activities. I give permission for camper to be medically treated for illness occurring or injury sustained during such participation and certify that he/she is covered by medical insurance which will reimburse the aforementioned Wesleyan Education Center for medical treatment ordered at their discretion and also to indemnity them for any expenses not reimbursed by such insurance. I have read the above: _________________________________________
________________
Parent’s Signature
Date Signed
1st—6th Grades
-OFFICE USE ONLY-
_ __
June 6-June 17
___ __ _ ___ __ _ C ut H er e an d R et u rn w i t h P ay me nt
PAYMENT & BILLING INFORMATION $75 per session
___
FEATURED ACTIVITIES: Skills Competency • Competition • Survival Skills Recreation Snorkeling • Water Basketball • Water Polo • Games
___
• Beginner to advanced classes available • Testing upon entry to ensure proper class placement • Smooth transitions between instructional levels • Self-paced advancement
___
As an active participant in our American Red Cross swimming program, your student will learn, develop, and refine their swimming skills, water safety, boating safety, and personal flotation device usage. In addition, Wesleyan Aquatics offers the following advantages:
___
Wesleyan Aquatics has been teaching swimming skills and water confidence to children for more than 30 years. We engage in a firm but gentle teaching approach, instilling joy and respect for God’s awesome creation of water. Our low student-teacher ratios allow our students to receive individual attention while benefiting from small, organized group sessions.
_ __
ABOUT WESLEYAN AQUATICS
Ck No: _________
Ck Amt: ____________
Cash Amt:: _______________
Staff Initials: ______________
