This form is for existing clients of Ansonia ONLY. If you are a new customer and are looking for information on our program, please email us directly at infantaquaticsct@gmail.com.
For all others that have already been in contact with us and are actively being scheduled, please complete all 4 boxes to register for our ANSONIA location.
REMINDER: ONLY ONE PARENT PER FAMILY
First Name
 
Last Name
 
Email Address
Phone Number