Full-Day Stroke Clinic

REGISTRATION FORM

SOLD OUT – Join the waitlist by filling out the form below. Do not make the payment unless we contact you. Thank you!

Please fill out the form below.

Name (first & last)

City/State

Date of Birth

Emergency Contact Name

Emergency Contact Phone Number

Do you have any food restrictions/preferences

Do you have any medical conditions or injuries we should be made aware of?

What is your swimming background?

What are your swimming goals?

What do you hope to gain from attending?

After submitting you will receive a payment link via email, once payment is complete your registration will be confirmed.

Questions? Comments? robin.barth9@gmail.com
(570) 337-1866