Survival Package – WET DOLPHIN SWIMMING ACADEMY

Student Type *New Student

First Name *

Last Name *

Email Address *

Confirm Email Address *

Phone *

Gender *BoyGirl

Age *

Lesson Days *Mondays & WednesdaysTuesdays & Thursdays

Preferred Time *

Start Date (Mon & Wed Only) *

Start Date (Tue & Thu Only) *

New Student Registration *Registration (Mandatory): $50

New Student Uniform *Uniform (Mandatory): $25

Regular Student ExtrasExtra Uniform: $75

Total US$

Name: {name-1-first-name} {name-1-last-name}

Email: {email-1}

Phone: {phone-1}

Gender: {radio-2}

Age: {number-1}

Student Type: {radio-1}

Package: {hidden-4}

Lesson Days: {radio-3}

Start Date: {date-1}{date-2}

Preferred Time (tentative): {select-1}

10 Lessons (2/weekly × 5 weeks)

$275.00

Registration

$50.00

Uniform

$25.00

Extra Uniform

$75.00

Order Total: ${calculation-1}

Credit / Debit Card *

Order Total