WISHART SHARKS SWIM CLUB

Name *

First Name

Last Name

Date of Birth *

Please note that this date is in AMERICAN format, so please put month first

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Allergies *

For example, but not limited to: bee stings, ant bites, food allergies etc

Yes

No

Breathing Disorder *

For example: Asthma

Yes

No

Ear Disorder *

Yes

No

Epilepsy *

Yes

No

Fainting / Dizziness *

Yes

No

Other relevant health conditions *

Yes

No

Name of Parent / Guardian *

First Name

Last Name

Date *

Please note that this date is in AMERICAN format, so please put month first

MM

DD

YYYY