All swimmers (or, if under 18, a parent or guardian) must complete this Medical Declaration Form before participating in any Club activities.  Please complete and return to any coach

 

Swimmer’s Details:

 

First Name:                                  Surname:                                                     DOB:                      Sex  M / F

 

Do you have any medical conditions eg diabetes, asthma**, epilepsy or heart problem?	Y  /  N
Do you use regular medication or have an inhaler?
Could this be required during training sessions or at a gala
Do you have any eyesight problems, including short sightedness?
Do you have any hearing problems?
Do you have any allergies e.g. to food or drugs?
Do you have any other relevant problems?

 

If YES, to any of the above, please give details, including any medication, and any supplementary information which may assist the Club in the event of an incident:

 

 

 

 

 

 

** if you take medication for asthma, (and you are a registered competitor) you are required to complete an ASFGB Medical Declaration Form annually, or sooner if it requires updating, and send it directly to the ASA as specified on the form.

 

In case of MEDICAL EMERGENCY affecting a child under age 18 a coach or Club representative will make every effort to contact a parent or guardian. If this is not possible, do you agree that the Coach or Club representative may act in loco parentis with respect to emergency first aid treatment including administering any prescribed medication defined above?

Y / N

 

I (parent if under 18) agree for the information provided above to be made available to the coaches and poolside staff of Barrow ASC and will notify the Club of any change.

 

Signature of swimmer (parent / guardian if under 18) …………………………………………Date: 

 

Full name of parent/guardian								Relationship to swimmer
Tel (home)				Tel (work)					Mob
Address
Postcode					Email

 

Please provide other contact details in case we are not able to contact above

 

Full name								Relationship to swimmer
Tel (home)				Tel (work)					Mob
Address
Postcode					Email