Brighton Dolphin Swimming Club Membership Application

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To be completed by members 18 years or over, or by parent / guardian of swimmers under 18 years old.

Title *

Miss

Mrs

Other:

First Name
*

Surname Name
*

Middle Name (if any)

Prefered Name

Date of Birth
*

YYYY

Address
*

Postcode
*

Ethnicity

Country of international Representation:

Parent full name (U18 Applications )

Relationship to Swimmer (U18 Applications )

Email address (Parent if U18): *

Home Phone Number

Mobile Phone Number (Parents if U18)
*

Emergency contact: (2 required) *

How did you hear about us?

Aims and ambitions for swimming:

Consent to receive club emails and newsletter? *

Yes

Does the swimmer have any physical medical conditions? If yes – please list and provide details: *

Does the swimmer have any allergies? If yes – please list and provide details

Does the swimmer take any regular medication? If yes – please list and provide details:

Any other relevant information? Please include all other medical conditions/disabilities:

Swimmers Doctor and Surgery Address *

Surgery telephone number: *

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