REGISTRATION FORM: Full-Day Stroke Clinics

JANUARY CLINIC IS SOLD OUT! Email robin.barth9@gmail.com to be put on waiting list. MARCH 10th IS STILL OPEN FOR REGISTRATION.

Please fill out the form below.

Name (first & last)(required)

City/State(required)

Date of Birth(required)

Emergency Contact Name(required)

Emergency Contact Phone Number(required)

Email(required)

Clinic Date Preferred:

January 14th

March 10th

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.

Submit

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