Enrollment & Release

Swim Lesson Enrollment & Liability Release

Complete this form once before your first lesson. All information goes directly to Suzi and is kept strictly confidential.

This form serves as your official enrollment and liability release for private swim lessons with Swim Lesson Suzi LLC. Please fill out every section as completely as possible — the more Suzi knows about your swimmer, the better she can teach them.

1. Participant Information

First Name

Last Name

Date of Birth

Age

Gender

2. Parent / Guardian

Required if the participant is under 18. Adult participants may leave this section blank.

Parent / Guardian Full Name

Relationship to Participant

3. Contact Information

Email Address

Phone Number

Home Address

4. Emergency Contact

Full Name

Relationship

Phone Number

5. Swim History & Experience

Current Swimming Level

Has the participant taken swim lessons before?

If yes, where? (school, instructor, or program name)

Has the participant ever had a frightening or traumatic experience in the water?

If yes, please describe what happened

On a scale of 1–5, how fearful is the participant of water? (1 = not at all, 5 = very fearful)

What are your goals for these lessons?

6. Health & Medical Information

All health information is kept strictly confidential and used only to ensure the participant's safety.

Does the participant have any medical conditions, diagnoses, or physical limitations?

If yes, please describe (e.g. asthma, epilepsy, heart condition, autism, ADHD, sensory processing, Down syndrome, cerebral palsy, etc.)

Allergies (food, environmental, medication, latex, chlorine, etc.)

Current Medications

Disabilities or special needs Suzi should be aware of

Physician / Pediatrician Name

Physician Phone

Anything else Suzi should know about the participant's health, behavior, or learning style?

7. Package Selection

Which package are you purchasing?

How did you hear about Swim Lesson Suzi?

8. Practice Swims Addendum

Complete this section only if you plan to book Practice Swims — private, unsupervised practice time in the lesson pool between lessons.

I request use of the Swim Lesson Suzi pool for practice swim sessions for myself and/or the minor children listed on this form. I understand that:

Practice Swims are not supervised lessons. No instructor or lifeguard is on duty.
I am fully responsible for supervising the minors in my care and will stay in the water within arm's reach of any child at all times.
Swimming has risks, including drowning, slipping and other injury.
I have read and agree to follow the posted Pool Rules. Practice Swim privileges may end if the rules are not followed.

I voluntarily accept these risks and release, waive and hold harmless Swim Lesson Suzi LLC, Suzi Teitelman, and the property owner from any claims for injury, illness, death or property damage resulting from use of the pool during Practice Swims, to the fullest extent allowed by law.

Parent/Guardian Initials

Date

9. Liability Release & Signature

Assumption of Risk & Release of Liability

I, the undersigned, acknowledge that swimming and aquatic activities involve inherent risks including but not limited to drowning, near-drowning, slipping, falling, and physical injury. On behalf of myself and/or the participant named herein, I voluntarily assume all such risks. I hereby release, waive, and discharge Suzi Teitelman and Swim Lesson Suzi LLC, its agents, and representatives from any and all liability, claims, or causes of action arising from participation in swim lessons, whether caused by negligence or otherwise. I certify that the participant is in good health and physically able to participate in aquatic activities, and that I have disclosed all known medical conditions below. I agree to follow all safety instructions provided by Suzi Teitelman.

I understand that Suzi Teitelman is a certified American Red Cross Water Safety Instructor and will take all reasonable precautions to ensure the safety of the participant. I agree to inform Suzi immediately of any changes to the participant's health or medical status.

Package & Cancellation Policy

Packages are non-refundable. Lesson credits never expire — use them whenever you're ready. Lessons may be cancelled due to lightning or severe weather; makeups will be arranged directly with Suzi.

Photo & Media

I grant Swim Lesson Suzi LLC permission to photograph or video the participant during lessons for instructional or promotional purposes, unless I indicate otherwise in the additional notes above.

By typing my full name below and submitting this form, I confirm that I have read, understand, and agree to all terms above. I certify that all information provided is accurate and complete to the best of my knowledge. This electronic signature has the same legal effect as a handwritten signature.

Full Legal Name (electronic signature)

Date

Your information is sent directly and securely to Suzi. It is never shared or sold.