Swim Lesson Registration Form 2023 Swim Lesson Registration Form Parent/ Guardian Name(Required) First Last Date of birth(Required) MM slash DD slash YYYY Participant's Name(Required) First Last Date of birth(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)Email Address(Required) LESSON TYPESSwim Lesson Options - MEMBER RATES Private Lessons - 1 Member 5, 30 minute lessons $140 Semi Private Lessons - 2 Members, 5, 30 minute lessons $240 Member FAC Sharks Swim Team - 1 month of practices $70 Swim Lesson Options - GUEST RATES Private Lessons - 1 Guest 5, 30 minute lessons $160 Semi Private Lessons - 2 Guests, 5, 30 minute lessons $260 Guest FAC Sharks Swim Team - 1 month of practices $85 FAC SHARKS SWIM TEAM AUGUST 2023 - Practice time Mon-Thu 6:00 - 7:00 PM SEPTEMBER 2023 - Practice time Mon-Thu 6:00 - 7:00 PM OCTOBER 2023 - Practice time Mon-Thu 6:00 - 7:00 PM NOVEMBER 2023 - Practice time Mon-Thu 6:00 - 7:00 PM DECEMBER 2023 - Practice time Mon-Thu 6:00 - 7:00 PM FAC SHARKSFAC Sharks is a competitive Swim Team. FAC Sharks is paid monthly and includes all practices, Monday - Thursday, 6:00- 7:00 PM. You may practice 1,2,3, or all 4 days each week. ADD ON - FAC SHARKS TEAM T-SHIRT - $12 ADD ON - FAC SHARKS SWIM CAP - $8 ADD ON- FAC SHARKS T-SHIRT/SWIM CAP BUNDLE - $15 Select AllPRIVATE LESSON DAY OF WEEK PREFERENCE MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY PRIVATE LESSON TIME OF DAY PREFERENCE MORNING AFTERNOON EVENING Credit Card Number Name on Card Expiration date (month/year) CVV Consent I agree to assume full risk and release all claims I and/or the participants may have against the Fayetteville Athletic Club (FAC), including it's agents, servants, and employees, from such claims resulting from injury, damages or loss sustained during participation in any FAC program or event. I understand that I am responsible for all personal medical insurance and the participant's family must cover any cost incurred. I also understand that every precaution is taken to protect the safety of all participants. I agree to any emergency treatment by a physician or hospital in the event that the emergency contact can not be reached.Signature Reset signature Signature locked. Reset to sign again Do you have any additional questions for our Aquatics Director? If everything looks good, please press "Submit" and our Aquatics Director will get back with you shortly. Δ
