CONTACT – Merritt Island Swim School

Parent Name *

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Last

Email *

Phone *

Address *

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City

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Zip Code

Student Name *

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Last

Student Date of Birth *//

Does your child have any Developmental, Emotional or Medical concerns that you would like to discuss with your Instructor?

Previous Water Experience

Preferred Lesson Time

Lessons are conducted 4 days per week, Monday - Thursday

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