SWIM QUESTIONNAIRE
SWIM QUESTIONNAIRE ______________________________________, _____________________________________ First Last 3 & 4 Year Olds Please Check Your 3 or 4 Year Olds Current Swimming Capability
Has your child had swim lessons before? Y__N__, Where? ______________How Many____ Your child’s attitude towards swim lessons?
Positive ___ Negative ___ Afraid___
Is your child comfortable in the water?
Yes ___ No ___
Does your child need a flotation device?
Yes ___ No ___
Check your child’s attitude towards face…..
Wet___ In-Water___ Underwater___
Check your child’s ability to jump into a pool.
Will not jump__ Will jump to an adult__
Will jump into “standing depth” only__
Likes to go jump & go underwater__
What type of kicking action mostly used?
Frog-Like Kick___ Flutter Kick___
Can your child Dogpaddle…….?
Only Head up___ Mostly Head-In ___
Does your child swim underwater?
Yes ___ No ___
Check your child’s floating ability.
Front/Face-in___ Back___ None ___
Does your child perform any stroke-like actions?
Freestyle__ Backstroke__ Breaststroke__
Does your child have any medical needs?
***Yes___ No ___ (If yes, please explain)
***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 ___ Beginner - Positive Introduction to Water: No face in the water and with support. ___ Advanced Beginner - Water Exploration: Face in the water for 10 seconds with support ___ Intermediate Advanced - Swim: Face in water for 10 seconds without support
WESLEYAN EDUCATION CENTER 1917 N. Centennial St., High Point, NC 27262 (336) 884-3333 Ext. 228 • [email protected] http://www.wesed.org/Page/Athletics/Aquatics/Aquatics-Offerings
CHILDCARE SWIM REGISTRATION
Wesleyan Aquatics has been teaching swimming skills and water confidence to young 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 for students aged 3 and up.
_____________________________, _______________________________, __________ First Last Rm.#
PAYMENT & BILLING INFORMATION $75 per session (Wesleyan Aquatics = 10 classes per Session / Piedmont - area programs = 8 classes per Session) MULTIPLE SESSION DISCOUNT: Register for 2 Sessions per Child
MAKE CHECKS PAYABLE TO:
Wesleyan Aquatics
By May 20th
One Check per Child PLEASE
Receive $10 Discount - Refund Policy -
Your child’s class ratio is very important to us.
June 20-July 1 Rooms 15,17,19, 20, 22 July 11-22
Rooms 10, 11, 16
July 25-Aug 5
Rooms 15,17,19, 20, 22 Please Retain This Page For Your Records
__ _ ___ __ _ ___
Rooms 10, 11, 16
_________________________________, _______________________________ Home # Cell # _________________________________________________________________ Email Address
_________________________________________________________________ Home Address (Street / City / St / Zip)
CHOOSE YOUR SWIM DATES SESSION ONE: __June 6-17, 2016
SESSION TWO: __July 11-22, 2016
Rooms 10, 11, 16
Rooms 10, 11, 16
__June 20–July 1, 2016
__July 25-Aug 5, 2016
Rooms 15, 17, 19, 20, 22,
Rooms 15, 17, 19, 20, 22
Please See Your Childcare 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. _________________________________________
________________
Parent’s Signature
Date Signed
___
June 6-17
_____________________________ Relationship to Child
I have read the above:
- OFFICE USE ONLY -
_ __
SWIM DATES
___
Therefore a $10 administrative fee will be assessed for any and all withdrawals or changes from your original swim registration.
_______________________________ Emergency Contact Name
__ _ ___ __ _ ___ __ _ C ut H er e an d R et u rn w i t h P ay me nt
• beginner to advanced classes available. • testing upon entry to ensure proper class placement. • smooth transitions between instructional levels. • self-paced advancement. • featured skills in survival, competency, recreation, and competition.
___
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:
_ __
ABOUT WESLEYAN AQUATICS
Ck. No: _______
Ck. Amt: _______
Cash Amt: _______
Date: _______
Staff Initials: _______
Has your child had swim lessons before? Y__N__, Where? ______________How Many____ Your child’s attitude towards swim lessons?
Positive ___ Negative ___ Afraid___
Is your child comfortable in the water?
Yes ___ No ___
Does your child need a flotation device?
Yes ___ No ___
Check your child’s attitude towards face…..
Wet___ In-Water___ Underwater___
Check your child’s ability to jump into a pool.
Will not jump__ Will jump to an adult__
Will jump into “standing depth” only__
Likes to go jump & go underwater__
What type of kicking action mostly used?
Frog-Like Kick___ Flutter Kick___
Can your child Dogpaddle…….?
Only Head up___ Mostly Head-In ___
Does your child swim underwater?
Yes ___ No ___
Check your child’s floating ability.
Front/Face-in___ Back___ None ___
Does your child perform any stroke-like actions?
Freestyle__ Backstroke__ Breaststroke__
Does your child have any medical needs?
***Yes___ No ___ (If yes, please explain)
***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 ___ Beginner - Positive Introduction to Water: No face in the water and with support. ___ Advanced Beginner - Water Exploration: Face in the water for 10 seconds with support ___ Intermediate Advanced - Swim: Face in water for 10 seconds without support
WESLEYAN EDUCATION CENTER 1917 N. Centennial St., High Point, NC 27262 (336) 884-3333 Ext. 228 • [email protected] http://www.wesed.org/Page/Athletics/Aquatics/Aquatics-Offerings
CHILDCARE SWIM REGISTRATION
Wesleyan Aquatics has been teaching swimming skills and water confidence to young 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 for students aged 3 and up.
_____________________________, _______________________________, __________ First Last Rm.#
PAYMENT & BILLING INFORMATION $75 per session (Wesleyan Aquatics = 10 classes per Session / Piedmont - area programs = 8 classes per Session) MULTIPLE SESSION DISCOUNT: Register for 2 Sessions per Child
MAKE CHECKS PAYABLE TO:
Wesleyan Aquatics
By May 20th
One Check per Child PLEASE
Receive $10 Discount - Refund Policy -
Your child’s class ratio is very important to us.
June 20-July 1 Rooms 15,17,19, 20, 22 July 11-22
Rooms 10, 11, 16
July 25-Aug 5
Rooms 15,17,19, 20, 22 Please Retain This Page For Your Records
__ _ ___ __ _ ___
Rooms 10, 11, 16
_________________________________, _______________________________ Home # Cell # _________________________________________________________________ Email Address
_________________________________________________________________ Home Address (Street / City / St / Zip)
CHOOSE YOUR SWIM DATES SESSION ONE: __June 6-17, 2016
SESSION TWO: __July 11-22, 2016
Rooms 10, 11, 16
Rooms 10, 11, 16
__June 20–July 1, 2016
__July 25-Aug 5, 2016
Rooms 15, 17, 19, 20, 22,
Rooms 15, 17, 19, 20, 22
Please See Your Childcare 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. _________________________________________
________________
Parent’s Signature
Date Signed
___
June 6-17
_____________________________ Relationship to Child
I have read the above:
- OFFICE USE ONLY -
_ __
SWIM DATES
___
Therefore a $10 administrative fee will be assessed for any and all withdrawals or changes from your original swim registration.
_______________________________ Emergency Contact Name
__ _ ___ __ _ ___ __ _ C ut H er e an d R et u rn w i t h P ay me nt
• beginner to advanced classes available. • testing upon entry to ensure proper class placement. • smooth transitions between instructional levels. • self-paced advancement. • featured skills in survival, competency, recreation, and competition.
___
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:
_ __
ABOUT WESLEYAN AQUATICS
Ck. No: _______
Ck. Amt: _______
Cash Amt: _______
Date: _______
Staff Initials: _______
