Scuba Registration Select Lesson/Class Type*ReactiveOpen Water $655Advanced $455Rescue $455CPR $55Emergency 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. Student's Current Level*Please select an option1st year StudentReturning StudentHas 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 agreeTotal $0.00 Credit Card*(Debit Cards are Not Accepted.) American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country PhoneThis field is for validation purposes and should be left unchanged.