Calendar

Swimmer's Name *

Swimmer's Surname *

Swimmer's Date of Birth Click here for calendar *

Address *

Post Code *

Swimming Club

Contact Telephone Number *

Email *

Each swimmer MUST complete a form.
They can find the form HERE.

Or, click here to email swimmers the link to the fom page

Swimmer 1 Full Name

Swimmer 2 Full Name

Swimmer 3 Full Name

Swimmer 4 Full Name

Swimmer 5 Full Name

Medical Details

Please choose Yes or No as appropriate and complete further details as necessary.

Does your child have any specific medical conditions requiring medical treatment and/or medication? Yes No

You have answered 'yes' to the above question. Please give details:

Does your child have any allergies? Yes No

You have answered 'yes' to the above question. Please give details:

Does your child take any medication for asthma? Yes No

You have answered 'yes' to the above question. Please give details:

Any other relevant information

Emergency Contact Details

In case of any emergency, please complete below alternative names, addresses, and telephone numbers i.e. another member of the family or a friend, who can be contacted should parents not be available.

It may be essential for SwimSkills staff to have the necessary authority to obtain urgent medical treatment which may be required during a swim camp. Please ensure you tick the Declaration/Consent box below to give the necessary authority.

Name *

Relationship to the swimmer *

Address

Telephone *

Add more Emergency Contact Numbers? Yes No

Please complete below any mobile telephone number/s which may be used in an emergency.

Mobile

Relationship to swimmer

Mobile

Relationship to swimmer

Mobile

Relationship to swimmer

In compliance with the Data Protection Act 1998, all efforts will be made to ensure that this information is secure and used only in connection with the activities of SwimSkills.

DECLARATION/CONSENT

• I am aware of and understand the potential risks associated with physical exercise and my child is voluntarily partaking in these activities with knowledge thereof.
• I have had the opportunity to ask questions regarding sporting and recreational activities and any questions I have asked have been answered to my satisfaction.
• The above questionnaire has been completed to the best of my knowledge and belief.
• Without prejudice to the above, SwimSkills accepts no liability for loss or damage of whatsoever nature and howsoever arising caused to my child or suffered by my child whilst on the clinic, UNLESS such loss or liability is caused by the negligent act of SwimSkills.
• I,being parent/carer of the above named child hereby give permission for the SwimSkills staff member caring for my child to give the immediately necessary authority on my behalf for any medical or surgical treatment recommended by competent medical authorities, where it would be contrary to my son/daughter’s interest, in the doctor’s medical opinion, for any delay to be incurred by seeking my personal consent
  

I have read and agree with the declaration above. *

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