Name of Swimmer *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Gender *

Please select from the options below.

Male

Female

Parents / Guardians Name *

First Name

Last Name

Contact Tel Number *

(###)

###

####

Are there any health Issues we need to be made aware of? *

Yes

No

Do you or your child have any special educational needs? *

Yes

No

Are there any allergies we need to be made aware of? *

Yes

No

Next of Kin (If different from Parent/Guardian)

First Name

Last Name

Next of Kin Contact Tel Number

(###)

###

####

How did you hear about us? *

Friends/Family

Social Media

Internet Search

Radio

Flyer

Preffered Day/Time *

Please select your prefered day/time slot. Unfortunately we cannot guarantee that your prefered time/day will be available.

Tuesday 12-12:30 (Plumpton)

Tuesday 15:00-19:00 (Plumpton)

Monday 17:30-19:30 (West Horsely)

Tuesday 17:30-19:30 (West Horsely)

Terms & Conditions *

Please click the box below to confirm you have read and agree to our terms and conditions before submitting this enquiry form.

I Agree