Includes Swim England Registration, County Affiliation and Insurance.
Member's Full Name *
Date of Birth *
MM
/
DD
/
YYYY
First Line of Address *
Post Code *
Home Phone Number (inc dialling code)
Parent/Guardian Name *
Parent/Guardian Mobile Number *
Parent/Guardian Email *
Additional Parent/Guardian Name (optional)
Additional Parent/Guardian Mobile Number (optional)
Additional Parent/Guardian Email (optional)
School Member Attends *
Please tick all that apply to Member *
Required
If you have ticked any of the questions above please give full details here.
[You must tick all boxes] I / we understand that by signing this form I / we: *
Required
I give Consent for Member to be photographed for LHSS publicity: *
Required
[Please tick one box] I agree to make payment of £50 using the following method by Fri 14 Feb: *
Required
Parent/Guardian print name below as Signature *
Submit
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