One with the Water, a 501(c)(3) non-profit

Online Registration

Step 1 of 3

Biographical

Waiver

Payment

Receipt

Please provide the swimmer's information below in order to complete your request. Swim session dates and times, and type of class will be selected on the next page.

Instructions To become a One with the Water® member, please complete this 2-step registration form. On step 2 you will be asked for your credit card (Visa, MasterCard, American Express, Discover) information. Once you complete step 2 and submit the form, you are immediately eligible to participate.

* Starred fields are required

First Name *	Preferred (Nickname)
Middle Name
Last Name *	Create Password

Gender * Female Male Birth Date * (mm/dd/yyyy)

Phone	Home/Primary *		Work/Secondary
	Cell/Other *		enter full number (555) 555-1212 x212

Email *

Street *
Street 2
City *
State*
ZIP *

USAT Number Exp. Date

Emergency Contact (Parent, Spouse, etc)
Name *		Relation
Phone *
Name 2 *		Relation 2
Phone 2 *

Does the swimmer have any allergies? *

If yes to the above question, please list allergens:

Is the swimmer allergic to bee stings? *

Any history of seizures? *

Anything else we should know about the swimmer?

How did you hear about us?

Would you like to choose your coach/instructor, if available?

Problem with this registration?