Southend RNLI New Year Day Dip 2018 - Online Entry Form
To participate in this event, please sign up before Wednesday 27th Dec 2017. At the end of the form, there are three options to pay your entry fee (£5). If we do not receive your entry fee, your entry form will not be processed and you will not be able to take part in the event.

For more information, please visit: http://southendlifeboat.org/activitybase/upcoming-events/southend-rnli-new-year-day-dip-2018/

If you have any questions or problems, please email: events@southendlifeboat.co.uk

Name *
Your answer
Address *
Your answer
Post Code *
Your answer
Telephone Number *
Your answer
Email Address *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Emergency Contact Name *
In the event of an emergency, we will contact this person. Please ensure they are able to take a call on the day, should it be required.
Your answer
Emergency Contact Number *
In the event of an emergency, we will contact this number. Please ensure the person is able to take a call on the day, should it be required.
Your answer
Emergency Contact Relationship *
What relationship is your emergency contact to you?
Your answer
How did you find out about the event?
Please detail
Your answer
Next
Never submit passwords through Google Forms.
This form was created inside of Activity Base (Southend RNLI). Report Abuse - Terms of Service - Additional Terms