LGBT Masters Aquatics Club

Synchronised swimming challenge 2017 - Sign-up form

To register for the course, please complete the following questions and, if necessary, make payment as indicated. If you are an existing member of Out to Swim, then you do not need to fill in this form and should email synchro@outtoswim.org to reserve your place.

If you answer yes to any of the physical activity readiness questions below, then you may be asked to see a doctor and/or to allow relevant medical information to be shared, in confidence, before training with Out to Swim.

PERSONAL DETAILS
Name *
Name
Address *
Address
Date of birth *
Date of birth
We ask this question on behalf of the ASA, you are not required to answer.
We ask this question on behalf of the ASA, you are not required to answer.
The Equality Act 2010 defines a person as disabled if they have a physical or mental impairment, which has a substantial and long-term (i.e. has lasted or is expected to last at least 12 months) and adverse effect on the person’s ability to carry out normal day-to-day activities. We ask this question on behalf of the ASA, you are not required to answer.
Emergency contact name *
Emergency contact name
Swimming ability
OUT TO SWIM CLUB MEMBERSHIP
If no, you will need to join Out to Swim in order to participate in the course.
For a one-off membership fee of £32 you will receive access to the synchronised swimming course for a period of 6 months. Please make payment by bank transfer to SC 30-96-38, AC 01012667 ensuring to include your name as Payee Reference.
ASA COMMUNICATIONS
Physical Activity Readiness Questions
I have answered this questionnaire truthfully and to the best of my knowledge. If my health or other circumstances change in ways that may affect my ability to exercise safely, I am responsible for informing Out to Swim. I am also aware of the risks associated with my chosen activity with Out To Swim and promise to share relevant information with Out To Swim so that those risks can be properly assessed and managed. I also understand that I have the right to say ‘no’ and withdraw from any proposed activity. *
I authorise Out to Swim to inform the relevant members of the club of any physical, medical or mental condition disclosed to ensure my safety and well being as well as that of other members of the club. Only those who need to know will be informed. I acknowledge that it is my decision whether to inform other members of the club. *
Agreement
I agree to abide by the rules of Out to Swim *