Student Registration

Student Information

Does the student have any allergies or medical conditions? *

Students Swim History / what you would like to achieve from the lessons

Guardian information

Email *

Address where lessons will be held:

Address

Street Address

City

Postal Code

Emergency Contact Information

Relationship to Student

I have completed and agree to the terms & conditions provided by Leisha's Mobile Swim School. By providing my phone number, I agree to receive text messages from the business.

common.challenge.bot_protection_label

I respect the privacy of your personal information. The information on this form is collected for the purpose of processing, managing and administering your registration. It will not be otherwise disclosed without your consent. If you wish to seek access
to your personal information or have any questions regarding the handling of your personal information, contact [email protected]