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Oma's Dolphin Swim Pre-Registration
First Name of Participant
Last Name of Participant
Parent/Guardian (if applicable)
Country
- Select a value -
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Norfolk Island
North Korea
Norway
Oman
Pakistan
Palau
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania
Thailand
The Former Yugoslav Republic of Macedonia
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Address
Address 2
City
State
Zip
Phone Number
Cell/Mobile Phone Number
Email Address
Preferred Swim Date 1
Date
Preferred Swim Date 2
Date
Preferred Swim Date 3
Date
Particpants Date of Birth
Date
Age of Participant
Height of Participant
Weight of Participant
What is the primary diagnosis?
What is the primary language spoken/understood?
Can the individual communicate verbally
No
Yes
Will being in a non-sterile ocean water environment present any potential health issues for the participant?
No
Yes
(due to open wounds, ports, and/or a compromised immune system)
Is the individual afraid of large animals or deep water where they cannot see the bottom?
No
Yes
Is the individual able to swim/float without assistance?
No
Yes
Is the participant able to walk without assistance?
No
Yes
Is the individual able to hold their legs stiff?
No
Yes
Does the individual have full use of their arms and hands?
No
Yes
Does the individual experience seizure activity?
No
Yes
Are they controlled medically?
Does the individual require any special equipment (wheelchair, leg braces, G-tubes, crutches, etc)?
Does the individual have any allergies?
Is the individual able to climb up a pool ladder without assistance?
No
Yes
Is the individual self-sufficient?
No
Yes
On a scale of 1 to 10 (Weakest 1 2 3 4 5 6 7 8 9 10 Strongest), please indicate the individualʼs strength level at present time.
- Select a value -
1
2
3
4
5
6
7
8
9
10
Please add any additional comments
How did you hear about the Oma Swim?
Leave this field blank
Dolphin Encounters
Premier Swim With Dolphins
Signature Swim
Shallow Water Dolphin Encounter
Dolphin Dockside
Painting With a Dolphin
Meet A Dolphin
Exclusive Family Dolphin Encounter
Trainer For A Day
Summer Camp
Touch Tank
Oma's Dolphin Swim Program
Meet Our Dolphins
Research & Education
Independent Research
Animal Care Internship
Veterinary Internship
Dolphin Facts
School Groups
Animal Advocate
Research Articles
Online Gift Shop
Specials