Private Special Needs Swimming Lesson Registration

Contact Person

Salutation

Name*

Phone*

Email*

Address*

When do you need swimming lessons?

Date

Please specify

How often would you like to meet?

Please specify

Where would you like to hold your lesson?

3 Preferred Timing

e.g.: Monday morning, Wednesday afternoon, Saturday evening

How many kids are you registering for?*

Kid #1

Name

Date of Birth

Gender

Kindly describe your child's condition*

Kid #2

Name

Date of Birth

Gender

Kindly describe your child's condition*

Kid #3

Name

Date of Birth

Gender

Kindly describe your child's condition*

Kid #4

Name

Date of Birth

Gender

Kindly describe your child's condition*

Promotion Code (If Any)

How do you know about Happy Fish?

Please specify

Who recommend you about us?

Remarks

*

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