Registration for Mediterra’s Swim Training Events Registration - Swim Event Participant InformationName Of Participant* First Last Email* Have you made a registration and payment for this event already?* Yes No You don't have to fill in the rest of your personal information if you have already filled out a registration for this event previously, and you will just pay the remaining amount. Gender* Female Male Your age at the time of training event...* Phone*Please include the country code.Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country .Your Training EventChoose the event type...* Private or Semi-Private Training OW Swim Clinic (1 day) Select your training scenario...* Single Lesson 60 minutes Single Lesson 90 minutes Lesson Series (over a few days) Weekly Lesson Series (over a few weeks) Select your training topic or event...* Custom Private Training Pool Comfort Series New Swimmer Series Freestyle Fundamentals Freestyle Advanced Different Strokes Swim Club (4-week pass) Swim Club (single visit) At which location?* Courthouse Fitness in Salem Oregon Mittleman Jewish Community Center in SW Portland Turner Lake in Turner, Oregon You may pay for one or more sessions now. Or you may complete this registration, enter $0 into the payment amount, then pay in cash at your first attendance. Just choose "I have made other payment arrangements..." at the end of this form. Which Swim Club session do you plan to attend? Which instructor will you work with?* Coach Jamee Small Coach Mat Hudson No Preference Are you a current member of Courthouse Fitness?* Yes No No, but I may be interested in membership Are you a current member of MJCC?* Yes No No, but I may be interested in membership What is the starting date for your training event?* Write either the scheduled starting date for the group training event, or the date you have agreed upon with your instructor for private lessons. Select your OW Swim Clinics...* Hagg Lake, Aug 1 Turner Lake, Aug 15 Crescent Lake, Aug 23 Waldo Lake, Sept 19 To register for the Willamette River Swim Clinics on July 10 and 17, please visit this registration form instead.Enter your training payment amount...* The non-refundable deposit is $80 per person. You may pay the DEPOSIT amount or more, pay the FULL AMOUNT, or pay the REMAINDER of your balance. Refer back to the Private Training page for lesson prices. Enter your OW Swim Clinics payment amount...* The non-refundable deposit for each swimmer is $20 for each clinic. You may pay the DEPOSIT amount or more, pay the FULL AMOUNT, or pay the REMAINDER of your balance. Refer back to the swim clinic page for prices. Total Payment $0.00 ..PaymentTotal payment you intend to make... $0.00 If this is not correct, you may go back and edit the payment amount on the previous page. Please read our Privacy Policy. By filling out this registration form, you agree to trust us with very limited use of your personal your data to provide coaching services to you. We do NOT share your information with anyone outside our administrators. You also agree to be added to a mailing list that enables us to send you information about this particular training event and Mediterra's services in general. You are welcome to unsubscribe from the list at any time by following the link at the bottom of each email. Please read our Terms and Conditions and our statement of Responsibilities, Waiver and Release.Do you agree to the terms of these three documents?* Yes No By submitting this registration you will be agreeing to the terms in these three documents, for yourself or on the behalf of the one you are registering for this event. It appears that you will not be able to complete the registration at this time. If you have concerns or questions regarding our terms for participation, we would be glad to have you contact us to discuss it. Select form of payment...* I will pay with my CREDIT CARD. I have made other payment arrangements with the Mediterra Office. Credit CardCard Details Cardholder Name Δ
