Tynemouth Amateur Swimming Club Ltd

Tynemouth Amateur Swimming Club

Application for Club Membership - Swimmer

The information on this form will be kept on a computer database - the information is confidential and will be accessed and used by authorised officers of the Club only.

First Name: / Middle Name:
Surname: / Known As:
DOB: /

Male/Female

Address:
Post Code:
Home Tel:
Email:
(This will only be used to keep you informed about Club activities and for invoicing purposes)
Country of Representation - this will be used for your ASA registration and identifies the (home) national championships in which you will be eligible to compete
England / Scotland / Wales / Other (specify)

Parent/Carer Contact Details*

Name:

Relationship:
Mobile Telephone:

* - Master’s swimmers/Tri-athletes should provide details of Next of Kin

Discipline - tick all that apply / Swimming / √ / Diving / Synchro
Masters / W Polo / Open Water

Are you/have you been a member of any other UK swimming club? Yes/No

If Yes which club? ______ASA registration number______

(if you have any current British Swimming Ranking times you may be asked to provide them)

Have you received teaching/coaching from any other facility? Yes/No

NTLP level achieved ____ Have you passed the Competitive Start award Yes/No

(You will need to provide documentary evidence of the above)

PTO

MEDICAL CONDITIONS

For example: heart, diabetes, epilepsy, hay fever, asthma, glue ear and any other known medical conditions. Please also list any specific learning difficulties.

New relevant health problems must be reported as they occur. Squad fees may be waived during periods of extended illness providing written notice is given.

Any Medical Condition1

Any Medication Required2

1 Tynemouth ASC, its employees or agents are not trained to provide medical advice and you must consult with your GP if you have any concerns about your health or fitness before taking part in any Club activity.

2 A parent or guardian will need to make their own provision to supply or administer any prescribed medication. It is not the responsibility of Tynemouth ASC, its employees or agents to supply or administer any prescribed, or un-prescribed medication under any circumstances.

Please select the nature of any disability you have:

Ambulant / Hearing / Learning / Visual / Wheelchair

Membership of TASC confers rights and obligations, which are described in the Club Rules & Code of Conduct. As well as completing this form you must also sign the declaration to say that you have read, and agree to abide by, the above documents.

Please note that all members are obliged to give written notice if they wish to terminate their membership. Fees will be charged until the date on which written notice is received.

CLUB USE ONLY
Date of Application: / SIGNED
Date of Assessment: / SIGNED
Membership Form Completed: / SIGNED
Date of First Joining: / SIGNED
Squad: / SIGNED
Entered onto Database: / SIGNED
Date of ASA Registration / SIGNED
Date of Resignation: / SIGNED