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Adult Swim Registration

Lessons can be paid for via all major credit cards.

There are no refunds in the event of a cancellation. If you or your child are unable to keep an appointment, you may reschedule for a later date. Please allow a 24 hour notice of cancellation.

Select Lesson/Class Type*
Emergency Contact Information

Adult students should use this area to provide your emergency contact information.
Contact Name*
First Last
Emergency Contact Phone:*
Student Information

Use this area to tell us more about who will be participating in our swim lessons.
Your Name:*
First Last
Your Phone Number:*
Your Email Address:*
Student's Birthdate:*
Give us your birth date and you could receive birthday specials.
Date Format: MM slash DD slash YYYY
Student's Current Level*
Has this student seen a medical specialist or had any non-routine health issues? Please explain.*
What is the Student's prior swim instruction/water experience?*
Photo/Video Release

I give permission to Powers Swimming and its instructors to photograph and/or record and to utilize photographs or other likenesses of me and/or my minor child(ren) on videotape, audiotape, photograph or any other medium in all forms of advertising, trade and any other lawful purposes including but not limited to: print advertising, photographs, video, website, and social media. I further consent to the use of my name, voice and/or biographical data in connection with such use.
Please select an option regarding photo/video release:*
- I have read the above statements and agree.
- I have read the above statements & DO NOT agree to a photo/video release. (If you choose this option, remind your instruction at the time of lesson to refrain from taking photo/videos).
Liability Release
I hereby release and forever discharge Powers Swimming Inc, its agents, employees, representatives, successors and assigns from any and all liabilities, claims, actions, damages, costs or expenses which I may have against any or all of them arising out of or in any way connected with my child’s use the pool area, including but not limited to, any injuries which may be suffered. The Facilities are defined as the swimming pool, the surrounding pool deck, lounging areas, picnic tables, pool chairs, bathrooms, adjacent walkways and any other areas contained within the boundaries of the fenced-in swimming pool area. I acknowledge and understand that it is the sole responsibility of Powers Swimming, Inc. supervise the activity.
Please select an option regarding Liability:*
- I have read the above statements and agree.
- I have read the above statements & DO NOT agree
Product Name
Select each swim accessory you'd like to purchase:
- Waterproof Car Protector
- Turquoise Goggles
- Yellow Rim Goggles
- Youth Blue Mask
- Black Adult Mask
- Blue Adult Mask
- Booties
- Fins
- Mermaid Bracelet
Total
$0.00
Credit Card*
(Debit Cards are Not Accepted.)

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
This field is for validation purposes and should be left unchanged.