Survival Swim Student Registration

You are registering for lessons with Rebekah McClain Ayer. If you HAVE NOT already reserved your start date/time with Coach Rebekah, please do not proceed with registration; instead, please contact us via Facebook Messenger or email ayer.rebekah@gmail.com.

2023 LESSONS ARE $100 PER WEEK PER STUDENT

You can also call Rebekah at 225-678-1175 if you have any questions about registration or need to reschedule lessons.

Swim Student Information

This participant is a: *

NEW Student

RETURNING Student

RETURNING Student of 3 seasons or more

First Name *

Last Name *

Gender *

Birth Date * +

Has this participant ever seen a medical specialist other than his/her primary care physician? Has he/she been diagnosed or treated for any developmental, medical, or health condition? Is there any follow up scheduled? In order for us to provide the safest and most effective lessons possible, please provide us with as much detail as you can. * 🛈

If other than "none", please explain: 🛈

0/255 characters

List ALL prior swim instruction/lessons: 🛈

Primary Care Physician *

Are you enrolling another student? *

Yes

No