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Do NOT re-enroll
Fill out the form carefully to cancel registration/enrollment
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1
Parent/Carer/Guardian/Responsible Adult Name
*
This field is required.
First Name
Last Name
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2
Email
*
This field is required.
example@example.com
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3
Child's Name
*
This field is required.
First Name
Surname
Please Select
Male
Female
Please Select
Please Select
Male
Female
Gender
Please Select
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Stroke
Transitional
Please Select
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Stroke
Lesson Type
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4
Do you have another child in the program?
*
This field is required.
YES
NO
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5
Would you like to cancel another child?
*
This field is required.
YES
NO
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6
Child's Name
First Name
Surname
Please Select
Male
Female
Please Select
Please Select
Male
Female
Gender
Please Select
Transitional
Stroke
Transitional
Please Select
Transitional
Stroke
Lesson Type
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7
Do you have another child in the program?
YES
NO
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Enter
8
Would you like to cancel another child?
*
This field is required.
YES
NO
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9
Child's Name
First Name
Surname
Please Select
Male
Female
Please Select
Please Select
Male
Female
Gender
Please Select
Transitional
Stroke
Transitional
Please Select
Transitional
Stroke
Lesson Type
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10
Do you have another child in the program?
YES
NO
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Submit
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11
Would you like to cancel another child?
*
This field is required.
YES
NO
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12
Child's Name
First Name
Surname
Please Select
Male
Female
Please Select
Please Select
Male
Female
Gender
Please Select
Transitional
Stroke
Transitional
Please Select
Transitional
Stroke
Lesson Type
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13
Do you have another child in the program?
YES
NO
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Submit
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14
Would you like to cancel another child?
*
This field is required.
YES
NO
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15
Child's Name
First Name
Surname
Please Select
Male
Female
Please Select
Please Select
Male
Female
Gender
Please Select
Transitional
Stroke
Transitional
Please Select
Transitional
Stroke
Lesson Type
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16
Reason for Leaving?
*
This field is required.
You can select more then one response.
Starting Primary School
Medical Illness
Holiday
Other Sports/activities
Financial
No Suitable time available
Unhappy with progress/program
Changing swim schools
Other
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17
If other please describe.
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18
Thanks for you time
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