Disability Swimming Sessions, 14th September, 12pm

Participant Full Name *

Participant Date of Birth *

Postcode *

Participant Ethnic Origin *

What gender do you identify as? *

If there is difficulty with any other area or any other way please state: *

Emergency Contact Name *

Emergency Contact Number *

Please provide further details and/or medical conditions that we should be aware of to best support the participant For example: Communication preferences e.g. makaton, BSL, non-verbal; Mobility aids used e.g. wheelchair, crutches; sensory needs, interests or triggers. *

In the past week, on how many days have you done a total of 60 minutes or more of physical activity, which was enough to raise your breathing rate? This may include sport, exercise, and brisk walking or cycling for recreation or to get to and from places. Include physical activity in and out of school/college and as part of your job etc. *

Media/ Photo Consent I give permission for images/footage to be taken of me whilst taking part. I understand that the images/footage may be used to promote the work of Access Sport and the partner club, for example on our website, social media or in authorised publications. *

I give permission as the parent/carer/guardian (under 18 only)

Yes

I give permission as the participant (over 18 only)

Yes

If you would like to sign up to the Access Sport Newsletter for updates on the latest inclusive sport and physical activity opportunities, then please provide your email address.

Disability Swimming Sessions, 14th September, 12pm

Get Social!