Summer camp swim program for children and adults with special needs in CT.

Swim Lesson Registration Form
Fill out, print and sign the following form, and fax it to 860-228-2091 or mail it to:
Easter Seals Camp Hemlocks, Aquatics Department,
85 Jones Street, PO Box 198, Hebron, CT 06248-0198

Registration Hint: Fill out the general information on the Swim Lesson Registration Form and photocopy it. This will save time for the next sessions, where you will only need to fill in the lesson information.

Participant Name:		Age:
Parent's Name:
Address:
City:
State:		ZIP:
Phone (home):
Phone (work):
Special accommodations/medications needed? Please explain:

Emergency Contact:
Name:		Phone Number:

Swim Lesson Classification Level:
1st Choice--Day:		Time:
2nd Choice--Day:		Time:
3rd Choice--Day:		Time:
Release/Waiver I waive and release any claim or action that I or the above individual may have against Easter Seals of Connecticut, Inc., or its officers, agents, or employees, with respect to any accident involving individuals while attending Easter Seals Camp Hemlocks activities.
Signature:	___________________________	Date:	__________________

Easter Seals Camp Hemlocks :: 85 Jones Street :: PO Box 198 :: Hebron, CT 06248-0198
Tel 860-228-9496 Ext. 200 :: Toll-Free 1-800-832-4409 Ext. 200(CT+RI Only) :: Fax 860-228-2091
info@eastersealscamphemlocks.org