Water Aerobics Registration Select Lesson/Class Type*Please select oneAerobics Classes 10 (1 hour) classes: $100.00Aerobics Classes $/hour single class - $15Emergency Contact Information Students should use this area to provide your emergency contact information.Emergency 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 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 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name Billing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code NameThis field is for validation purposes and should be left unchanged.