Kirkham and Wesham ASC sign up form

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Name *

Date of birth *

Gender *

Telephone number *

Email address *

Home address *

Medical information *

Please include any primary and secondary disabilities. All disclosures will be kept confidential and only shared when appropriate to do so.

Allergies *

Yes

If yes please provide information

Emergency contact 1 *

Please provide name, number and relationship to swimmer

Emergency contact 2 *

Please provide name, number and relationship to swimmer

Ethnicity *

Is this the only club that the swimmer is a member of? *

Yes

If yes please provide the name of the other club

Photography

The club may wish to take photographs or film individuals and groups of members under the age of 18 that may include you child during their membership. All photographs and filming and all use of images will be in accordance with the Swim England Photography and Filming Guidance and the club privacy policy. The club requires consent to take and use photographs. Parents/Guardians have the right to refuse agreement to their child being photographed. As the parent/guardian please indicate your permission below. Please note you can withdraw your consent at any time should you wish to do so. This must be done in writing to the club welfare officer.

As the parent/guardian I am happy for my child's photograph to be used on the club's website *

Yes

As the parent/guardian I am happy for my child's photograph to be used on the club's social media platforms
*

Yes

As the parent/guardian I am happy for photos of my child to be included in the newspaper
*

Yes

As the parent/guardian I am happy for photo's to be taken by a professional photographer at events *

Yes

As the parent/guardian I consent to filming for training purposes *

Yes

Please read the code of conduct for our swimmer's and sign below.

Agreement *

I agree to the code of conduct for swimmers

Please read the code of conduct for parent's/guardian's and sign below

Agreement *

I agree to the code of conduct for our parent's/guardian's

I confirm that I have read, and agree to abide by the code of conduct and club policies. I acknowledge receipt of the rules of Kirkham and Wesham Swimming Club and confirm my understanding and acceptance that such rules shall govern my membership of the club. I further acknowledge and accept the responsibilities of membership upon members as set out in these rules.
*

Yes

Please print name and date in box below
*

I being the parent/guardian hereby give consent to the use of this information by the club for the protection and safeguarding of my child's health. I also give permission for the Coach, Team Manager, or other club officer 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 personal consent.

I understand that the club may still have a lawful need to use this information for such purposes even if I later seek to withdraw this consent.

Yes

Please print name and date in box below *

Submit

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