Valley Isle Aquatics Registration Form

Session: Individual Lessons

Session Location: Will be determined after confirmation from instructor.
Session Dates: Dates are determined by the Instructor and the Student.
Session Cost: Total Cost is dependent upon number of lessons; generally it is $15.00/30 minute class.

Note: Items marked * are required fields

Personal Details

Student's First Name*
Student's Last Name*
Parent's/Guardian's First Name*
Parent's/Guardian's Last Name*
Email Address
*

*Please do provide your email as this is our only way of sending you a confirmation email.

Student's Age*
Student's Birthdate*
Student's Gender* Kihei UpCountry Central

Address Details

House Number & Street*
Town/City*
State*
Zipcode*
Home Phone*
Cell Phone*
Work Phone*

PayPal Details

PayPal Account Name*
Email Address (listed with PayPal)*
Company Name (listed with PayPal)*

*Your PayPal Account Name is essential for us to match the registration form and payment.

Please check the boxes according to which level, day of the week, time, number of lessons, and location you are interested.
Please do NOT submit a blank registration form, this only delays the process and does NOT guarantee your child a spot in the class.
Your child will NOT be enrolled in a class until your payment and completed registration form is received.
AND you receive a confirmation email from us.

Levels & Times	10:15	11:15	12:15	1:15	2:15	3:15	3:15-3:45	3:45-4:15
Pre-School Red
Pre-School Red-Orange
Pre-School Orange

Red
Red-Orange
Orange
Orange-Yellow
Yellow
Yellow-Green
Green
Middle School
Adult
Parent-Infant
Parent-Toddler

WSI Class
Lifeguard Training
Lifeguard Training Challenge Course
Challenge Course

I give my consent/permission to Valley Isle Aquatics to use my child's picture/image. Full Policy
I do NOT give my consent/permission to Valley Isle Aquatics to use my child's picture/image.

Submitting this registration form does NOT guarantee you a spot in the class.
Please be aware that classes with fewer then four (4) students will be CANCELLED!
There are NO REFUNDS.
Read the full Refund and Cancellation Policy.
By submitting this registration form, you agree with the terms listed below.

Please wait to make your payment until you have confirmed everything with the instructor.

Valley Isle Aquatics PO Box 367 Haiku, HI 96708 (808) 572-4665 or (808) 269-4166
valleyisleaquatics@valleyisleaqutics.com
(C)2010-2012 Designed by Maui Tech Girl

County of Maui
Department of Parks & Recreation
Community Classes

The County of Maui does not discriminate on the basis of disability in admission, access to,
or operation of its programs, service, or activities.
The County of Maui does not discriminate on the basis of disability in its hiring or employment practices.
We are committed to making all of its programs and leisure services accessible to everyone including persons with disabilities.
Do you have need for reasonable modifications? _____ Yes _____ No
Question, concerns, complaints, or requests for additional information regarding compliance
with the Americans with Disabilities Act may be forwarded to:
Community Courses Office
Floyd Miyazono
700 Haliÿa Nakoa Street #2
Wailiku, HI 96793
(808) 270-7383 voice
floyd.miyazono@mauicounty.gov

Release and Covenant Not to Sue
In consideration of the permission granted to me by the Department of Parks and Recreation of the County of Maui,
State of Hawai'i, to attend or participate in the above described a"Calibri"ctivity
>I, the undersigned, hereby release the above named Instructor and the County of Maui, its officers and employees,
from all actions, causes of action, damages, claims, or demands which
I, my agents, successors, assigns, heirs, executors or administrators, may have against said Instructor or the County of Maui,
its officers and employees, for the property damage and personal injury, including but not limited to
claims for wrongful death, known or unknown, which may be
sustained or incurred by my attendance or participation in the above described activity.
I also covenant, on behalf of myself and my agents, successors, assigns, heirs, executors or administrators,
to never institute any legal action against said Instructor or the County of Maui,
its officers and employees, or in any way aid in the prosecution of
any claim or action for damages, costs, loss of services, expense or compensation,
arising our of my attendance or participation in the above-described activity.
I, the undersigned,
have read this release and Covenant Not to Sue
and understand all its terms. I execute it voluntarily and with full knowledge of its significance.