Beginners Swimming Registration: Youth (11-16 yrs)

Request edit access

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Mondays 7:15pm - 7:45pm (arrival 7:10pm)
Chiltern Wood School, Faulkner Way, Downley, High Wycombe, Bucks, HP13 5HB
Atia: 07543 015897

£5 per session - block booking, payment to be paid upfront.

PARTICIPANT'S DETAILS

First Name: *

Last Name: *

Telephone Number: *

Date of Birth: *

YYYY

Age: *

Email Address: *

Ethnicity: *

What is your postcode? *

PARENT/GUARDIAN'S DETAILS

Name: *

Telephone Number: *

Email Address: *

ICE (in case of emergency) DETAILS:

Emergency Contact's Name: *

Emergency Contact's Number: *

Relation: *

MEDICAL QUESTIONNAIRE

Regular exercise is associated with many health benefits, yet any change of activity may increase the risk of injury.
Please complete questionnaire to help us avoid injury to you.

1.) Do you have any long term illness, health problem or disability that limits your daily activities?

2.) In the past 4 weeks, on how many days have you done 30 minutes of sport and/or recreational physical activity? Do not count any curriculum activities at school/college. Do not include cycling or walking unless it was for sport or recreation. Gardening, DIY and housework should not be included. Please write in the number of days between 0-28: *

3.) Has a doctor ever stated you have a heart condition for which physical activity needs clearance by a doctor? *

4.) When you do physical activity, do you feel pain in your chest? *

5.) Have you experienced chest pains in the last month, whilst not being engaged in physical activity? *

6.) Have you ever experienced a loss of consciousness or do you lose your balance because of dizziness? *

7.) Do you have a joint or bone problem that may be made worse by a change in your physical activity? *

8.) Is a doctor currently prescribing medication(s) for any long term conditions? If so, please provide details. *

If you have answered “YES” to any of the above questions, please check with your doctor BEFORE you join sessions.

TERMS & CONDITIONS

Not all activities are suitable for everyone. If you ever feel any discomfort or pain, do not continue. You should understand that when participating in any activity or activity programme, there is the possibility of physical injury or even death. Karima Al Marwaziyya Foundation accepts no liability for injury, illness or health problems arising from your participation in any activity or activity programme you receive. You are voluntarily choosing to participate in an activity and you agree that any information, instruction or advice obtained from Karima Al Marwaziyya Foundation’s activity session will be used entirely at your own risk. You agree to disclose any physical limitations, disabilities, ailments or impairments to your health that may affect your ability to participate in any session and take part entirely at your own risk.

Karima Al Marwaziyya Foundation will not be responsible for loss, damage or theft of individual’s property or belongings on the site. You will agree to comply with appropriate conduct and use of facilities. You will also adhere to attire suitable for the activity.

Charges apply per session. No refunds will be made in the case of non attendance by a participant.

The facilitator reserves the right to exclude anyone from the session on medical grounds or excessive lateness. Karima Al Marwaziyya Foundation may make reasonable changes to the times of sessions, provided it gives advanced notice of these changes.

DECLARATION

By selecting the "signature" button, you are signing this agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this agreement.

My child & I agree to comply with the above terms and conditions. *

I give permission for my child to be photographed and images used for promotion. *

I have completed the medical details above and I consent that, in the event of any illness/accident, any necessary treatment can be administered to my child, which may include the use of anaesthetics. *

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms