Swim Clinic Medical Form

Swimmer Information

Swimmer First name

Swimmer Last name

Swimmer's Birthday

Day

Month

Year

Swimming Club

Parent Name

Parent Email

Parent Phone Number

Address

Medical Information

Emergency Contact Name

Relationship to Swimmer

Emergency Contact Phone Number

Do you have any medical conditions requiring treatment or medication, or allergies?

Yes

If yes, please provide details

Do you have any dietary or nutritional supplements?

Yes

If yes, please provide details including dosage and frequency

What type of pain relief (if any) may be given if considered necessary?

Does your child suffer from Asthma? If so are they taking medication (please provide details below)

Does your child have an up to date tetanus vaccination?

Yes

Does your child suffer from any disabilities (physical, visual, hearing or learning) or recognised behavioural problems that could effect their behaviour when training or in competition? If so, please give details :

Is there any other information the organisers need to be aware of?

Doctors Name and address and Telephone Number

Wiffen Twins Swim Clinic Cost

When you press submit you will be directed to the payment page.