Online Entry - Cumbria ASA

Event

Swimmer Details

Swimmer Name

Club

Event

I accept the invitation to represent Cumbria on 5th-6th October 2024

Swim England No

Date of Birth

I will be joining the bus at

Email

Emergency Contacts

Emergency Contact 1: Name

Emergency Contact 1: Phone

Emergency Contact 2: Name

Emergency Contact 2: Phone

Home Phone

Medical Declaration

Name of GP

GP Phone No

GP Address

Past Medical History: Please inform us in the box below of any past medical condition/s

Current Medical Conditions/Disability: Please inform us of any current relevant conditions

Current medications being taken

Allergies: Please inform us of any Allergies including medications

ALL INFORMATION WILL BE CONFIDENTENTIAL AND AVAILABLE ONLY TO THE TEAM MANAGEMANT

For any swimmer under the age of 18, IT IS IMPERATIVE, that the Team Management has the necessary authority to obtain any urgent treatment, which may be required. Please get your parent / guardian to complete the following.

Confirmation

I being the Parent / Guardian of the above named child hereby give permission for the Team Management to give the immediate necessary authority on my behalf for any medical or surgical treatment recommended by competent medical authorities, where it would be contrary to my son’s / daughter’s interest, in the doctor’s medical opinion, for any delay to be incurred by seeking my personal consent.

Parent Name

Date of Agreement

It is also important that the team management have permission to act “in loco Parentis” for under 18 year olds, please sign below to give this consent.

Parent Name

Date of Agreement

Photography Consent

Online streaming

I understand the event maybe streamed online by the promoter.

Photography

I agree to my child been photographed during the weekend, the photographs maybe used online and on social media to promote swimming within the county.

Code of Conduct

Code of Conduct can be viewed HERE

Parent/Guardian

I confirm that I have discussed the Cumbria ASA Inter Counties Code of Conduct with my child and have ensured they understand the contents and are aware of the expectations upon them.

Team Kit

Would you like to order team kit?

Yes

No

Have you previously purchased kit for National Inter-Counties Team event?

Yes

No

Product

Polo Shirt

Hoodie

Product

Polo Shirt

Hoodie

Polo Shirt Size

Hoodie Size

Name on Clothing

Total