Contact Form
Parents Name
*
First Name
Last Name
1. Child's Name
*
First Name
Last Name
Date of Birth
*
2. Child's Name
First Name
Last Name
Date of Birth
3. Child's Name
First Name
Last Name
Date of Birth
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Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
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Swimming Certificates Achieved
Medical Conditions
*
Asthma.
*
Yes
No
If Yes to above do you have an inhaler?
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I consent to photographs of my child/children to be used on LSA's website/facebook/general marketing
*
Consent given
Consent not given
i consent toLSA collecting and using my contact details in regards to swimming related business
*
Yes
Submit
Should be Empty: