Swim Lesson Registration Form - 2015/2016

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YMCA OF BOULDER VALLEY
AFTER SCHOOL SWIM LESSONS
2015-2016 SCHOOL YEAR
Registration: Please turn in non-refundable payment with fall registration packet or with your program site director. Lessons do fill up and space is dependent
on availability of aquatic staff and bus seats.
Transportation: Transportation by a YMCA vehicle is provided to swim lessons to the Mapleton Y (2850 Mapleton Avenue, Boulder, CO 80301). Our staff
accompany the children. Parents will pick up their children between 5:45pm and 6:00pm at the Mapleton Y In the lobby. Photo IDs are required at each pick up
time. Due to safety issues children will not be showering and may not be picked up from the pool or locker rooms.
Please provide plastic bag for suit and towel. All participants must be enrolled to attend the day the lesson occurs. Families registered for drop-in plan must pay
daily drop-in fee for swim lesson days in addition to swim lesson fee as they are in the care of our staff.
Lesson Evaluation: Each lesson is 45 minutes long. On the first day of lessons, each child will be given a “Skills Evaluation.” At that time children will be grouped
with other children of similar ability based on three different skill levels. At the end of the session, each child will receive a skill card with an evaluation of the
swimmer’s skills for the appropriate level.
Fee: $80 per session per child. Includes transportation and lessons with aqautics staff.
Swimmer’s Name____________________________________________________________ School _________________________________________Grade _________ DOB ___________________ Gender: Male
Female
Address ___________________________________________________________________________________________________________________________ City ___________________________________________Zip __________________________
Parent/Guardian Name _____________________________________________________________________________________________ Email __________________________________________________________________________________
Home Phone ____________________________________________________________ Cell Phone ________________________________________________ Work Phone ________________________________________________________
Parent/Guardian Name _____________________________________________________________________________________________ Email __________________________________________________________________________________
Home Phone ____________________________________________________________ Cell Phone ________________________________________________ Work Phone ________________________________________________________
Please check school and sessions you would like to register for.
Mapleton Y
Tuesdays Select school (North Boulder): Whittier
Crestview
Columbine
Foothill
Uni Hill
Flatirons
SESSION A
SESSION B
SESSION C
SESSION D
Sept 15-Oct 20
Oct 27-Dec 8
Jan 26-March 1
March 8 -April 19
Thursdays Select school (South Boulder): Eisenhower
High Peaks/BCSIS
Mesa
Bear Creek
Creekside
SESSION A
SESSION B
SESSION C
SESSION D
Sept 17-Oct 22
Oct 29-Dec 10
Jan 28-March 3
March 10-April 21
YMCA Financial Assistance pays same percentage as authorized for School Age Care. CCAP Parents pay $30 per session.
Please list any medical conditions or allergies your child has: _____________________________________________________________________________________________________________________________________
Waiver: My child is in good health and is capable of participating in YMCA swimming lessons. I understand the potential risks of participation and hold harmless
the YMCA, staff, directors and volunteers from accidents resulting from participation. I authorize, in a medical emergency, after reasonable effort has been made
to notify parents, that a YMCA representative may seek emergency assistance at the parent/guardian’s expense. Parents will pick up their children between
5:45pm and 6:00pm at the Mapleton Y. Photo IDs are required at each pick up time. Due to safety issues children will not be showering and may not be picked up
from the pool or locker rooms.
Payment Method: Check# __________________________________________________________________________________________OR Credit/Debit (check one) VISA
MC
AMEX
DISC
Name on Card _______________________________________________________________________________________________________ Card# __________________________________________________________________________________
Exp __________________________ VCODE _________________ Signature ____________________________________________________________________________________________________ Date _________________________________
Parent/Guardian Signature _________________________________________________________________________________________________________________________________________________________________________________
Internal Use Only
Registered at: Mapleton Y
Arapahoe Y
Program Site: _____________________________________________________________________________________________________________________________________
Intake Name ___________________________________________________________________________________________________________Date __________________________________________________________________________________
Registration Specialist _____________________________________________ Date _______________________________ Billing Name ______________________________________________ Date _____________________________

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