Book Class

Name

Layout

Email

Phone

Who's is taking part in the swimming?

Me (Adult)
Child

Childs Name

Layout

Relationship To Child

Emergency Contact Number

Please select the category that best describes the swimmers ability:

Has the swimmer had swimming lessons before and if so, what stage did they achieve? (If you are unsure of the stage awarded, please give an indication such as swims with arm bands, 5m or 25m badge.)

Does the swimmer have any fears or barriers that may affect their swimming lessons?

Does the swimmer have any special needs that impact on their session?

Booking Session

Have you got a discount code?

Yes
No

Discount Code

Enter Discount Code

Health Questionnaire – Physical Activity Readiness Questionnaire (PARQ Form)

Has your doctor ever said that your child has a heart condition and that your child should only do physical activity recommended by a doctor?

Yes
No

Does your child ever experience chest pain during physical activity?

Yes
No

Does your child lose their balance because of dizziness or ever lose consciousness?

Yes
No

Does your child have a bone or joint problem that could be made worse by a change in physical activity?

Yes
No

Does your child have asthma and require an inhaler?

Yes
No

Is your doctor currently prescribing any medication for your childs blood pressure or heart condition?

Yes
No

Has your child ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)?

Yes
No

Please explain your child's pain or injuries further.

Does your child have any allergies such as stings and require an auto injector for food allergies?

Yes
No

Please explain your child's allergies further.

I have read and agree to the New Forest Swim Academy terms of service, available to read at www.nfsa.co.uk/terms

Yes

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