Swimming Academy Confirmation And Medical Form (Page 2 of 2) in pdf

Swimming Academy Confirmation And Medical Form Page 2

Medical Conditions

Yes

7. Does your swimmer have any history of:

Asthma

Diabetes

Sight impediment

Hearing impediment

Injury or illness

Other

If yes, details please:

8. Is there anything else we should know about your swimmer that would

affect their participating, or others, or would adversely affect the health

and well being of other people on the trip?

Your name, address and contact phone

Your Doctor’s name and phone number:

number:

Name:

Dr’s Name:

Address:

Phone:

Phone (Work):

Phone (Home):

PLEASE NOTE:

(a)

Please have your child bring spares of any medication for their Instructor to carry.

(b)

Your swimmer will be covered by the normal public liability insurance while on this

camp.

(c)

While at camp your swimmer’s personal effects are NOT covered by our insurance

policy. You should ensure your insurance company would cover all eventualities.

As a parent/caregiver of

I hereby give my consent

for him/her to participate in the above mentioned swimming meet. I have read and understood

the information at the start of this form regarding risk and safety precautions. I have

explained to my son/daughter that normal Academy rules apply during the trip and that

following rules and the directions given to them by Instructors is necessary for their safety and

wellbeing. I understand that the costs will be charged to our son/daughter’s school account.

I delegate my parental authority and responsibility to the Academy coaches and Team

Managers involved and in the event of accident or illness, I authorise any medical assistance

and treatment as necessary.

Signature of Parent/Guardian:

Date: ____/____/_______

Swimmers Signature:

Date: ____/____/_______

Please return to: Pool Office, St Peter’s School, Cambridge, Private Bag 884 or fax to 07 827 9812

S:SportSwimming AcademyAcademyTemplates and FormsConfirmation and Medical Form 2013 REVISED VERSION.docx

Swimming Academy Confirmation And Medical Form Page 2

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