REGISTRATION FORM

DATE: LOCATION:

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NAME OF LEARNER: of
Learner
DATE OF BIRTH: GENDER:

SCHOOL/COLLEGE/ORGANIZATION:

PARENTS NAME:

EMAIL ID:

CONTACT NO.: WHATSAPP NO.:

EMERGENCY CONTACT NAME & NO.:

AQUAPHILE ACADEMY
RESIDENTIAL ADDRESS:

MEDICAL CONDITION/DISABILITY:

ENROLLING FOR: Swimming- Basic Intermediate Advance

Competitive
Aqua Aerobics Aqua Meditation Aqua Therapy Aqua Yoga
Aqua Flush Aware Aqua Detox Dive-IN Retreat
Personal Consulting (Mention Domain) _______________________
FEES PAID: (NON-REFUNDABLE): _________________________________

I hereby declare that the details mentioned by me above are true. I confirm that I
am free to take the learning sessions and do not have any diseases or infections
that can hamper my learning or my co-learners. Any incident happening due to my
negligence or incorrect information will be my sole responsibility. I will not hold the
coach or Aquaphile Academy responsible for any mishap whatsoever because I
understand the happenings are not always in someone's hand. I will abide by the
instructions of the Coach throughout and follow the rules to speed up my learning.

SIGNATURE OF LEARNER: _________________________________________

(Only if 18 Years+) (Parent/Guardian requested to sign for learner below 18 Years)

SIGNATURE OF COACH/CO-ORDINATOR: __________________________