Personal information

First name*
Last name*

Address*

ZIP code*

City*

E-mailaddress (for information and zwemscore)*

Phone number

Date of birth*

Gender*
Man Vrouw

Information activity

For which activity you would like to register?*

For which location would you like to register?*

Preffered swimming day; please choose 2 days*

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

From which time can your child participate classes? (if the lessons are for a child)*

Use of medicine or medical information that we should be aware of:

Use of E-mail address for information and zwemscore*
Yes, I give swimming school Aquayara permission to use my e-mail address for information of the swimming lessons and also to use zwemscore (the online swimming process system) No, I don’t give permission to use my e-mailaddress beside the confirmation of my registration. I do understand I can not participate to the online swimming process system.

Payment contribution en registration fee through automatic debit*
Yes, I give permission to automatic debit for the contribution and registration fee. I will give my bankaccount data below. (The contribution will not be taken until you or your child will participate the swimming classes) No, I will pay the registration fee en contribution by myself. U don’t need to fill your bankaccount information below.

Iban- number for automatic debit of the registration fee and contribution

The name of the person who owns the bankaccount above:

Do you have any notes for us?

Enter security code.

By sending the form, you agree with the terms and conditions of swimming school Aquayara.

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