Coach Victoria wants to get to know you better before your first swim. Please fill out the new swimmer intake form as part of completing your registration. Questions? Call Coach Victoria at (808) 319-8837

SWIMMER INTAKE FORM

SWIMMER’S NAME *

First

Last

Parent’s Name *

First

Last

Swimmer’s Date of Birth: *

Home Mailing Address *

Phone Number

Email *

Please describe swimmer HISTORY and GOALS:

Allergies, Fears, Stories or Comments:

Level of Fear

Selected Value: 0

0 is not afraid at all and 10 is very fearful

Submit