Please enter ALL information:

PLEASE READ: A non-refundable $20 deposit is due within 7 days of registration
This deposit will be put towards the cost of the class.
If no deposit is recieved your registration will automatically be removed from the system.

First Name:
Last Name:
Address:
City:
Zip Code:
Students Birthday :
mm/dd/yyyy (e.g. April 8, 2004 would be "04/08/2004")
Phone:
 (no dashes)
Contact Name / Parents Name:
Emergency Information
In the unlikely event that we need to contact a parent or guardian ASAP, who should we call?
Emergency Contact:
Emergency Contact Number: (no dashes)
E - Mail Address:
Class:
Extra Information:

Please let Revere Aquatics know of any personal or medical conditions.
All information is and will be kept confidential.

|
Revere Aquatics Inc. | 176 Garfield Ave- Revere, MA 02151
(781) 284-7865