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 *     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?


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