Pine Lake Stroke Clinic Registration

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Participant Information

Swimmers Name*
Date of Birth*
Gender:*
Swimmer is a:*
Parent is a:*

Reservation Request For

Stroke Session Dates*

Contact Information

Contact Name*
Address*

Policies and Procedures

Enrollment Procedures

  • Submitting this form is confirming your request for the swimmers enrollment into lessons and all indicated session dates.
  • Request forms will be sorted by when recieved as well as by Member and Non-member.
  • Participants will receive payment receipt and email confirmation upon enrollment.

Cancellation and Refunds

  • Cancellation or un-enrollment from future sessions or classes must be received by email.
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