BLAQ MERMAIDS REGISTRATION FORM

Email*

Name of Payee*

Email of Payee*

Payment Plan*

Monthly

Per Term

Installments

Other

Address Where you stay*

Name of Student*

Date of Birth*

Age*

Gender*

Male

Female

Other

Swimming Goals*

Which Program do you want to join*

Babies & Toodlers

Learn To Swim

Stroke School

Open Water

Workshop Events

Event Perfomance

Other

Which venue do you want SANDTON/BALFOUR*

Balfour

Sandton

Scatterlings Preschool

Other

Swim Slot You want to book for*

Incase of Emergency Contact Name*

Incase of Emergency Contact Surname*

Incase of Emergency Contact Number*

Incase of Emergency Contact Relationship*

Name & Surname of someone taking the child incase you're not available*

Disabilities / Handicaps /Allergies / Medical Conditions / Anything we should be made aware of*

Where did you hear about us*

Registration Information