OCTOPUS   SWIMMING   CLUB

                                                                 MaryArrigan- Langan

                                                                             206 Lurgan Park, Renmore.

                                                                                                       Tel: 091  756520(H)

                                                                                                  

                         I wish to apply for membership of the above club for swimmers with disabilities.

 

               FULL NAME:…………………………………………………………………………………….

               ADDRESS:………………………………………………………………………………………..

                                 …………………………………………………………………………………………

                                 …………………………………………………………………………………………

               TELEPHONE:…………………………………………………………………………………….

               DATE OF BIRTH:…………………………..

               NEXT OF KIN:……………………………………………………………………………………

               ADDRESS AND PHONE NUMBER:……………………………………………………………

               …………………………………………………………………………………………………….

               WHAT IS YOUR PHYSICAL DISABILITY:……………………………………………………

 

               Have you any of the named problems:

VISUAL  DIFFICULTIES                                  YES/NO

HEARING DIFFICULTIES                                YES/NO

FITS                                                                     YES/NO

DIABETIC                                                           YES/NO

HIGH BLOOD PRESSURE                                YES/NO

HEART CONDITION                                         YES/NO

ASTHMA  OR BRONCHITIS                            YES/NO

NERVE OR MUSCLE COMPLICATION         YES/NO

SKIN PROBLEMS                                              YES/NO

 

               IF YES TO ANY OF THE ABOVE, PLEASE GIVE DETAILS:………………………………… 

               ………………………………………………………………………………………………………

               ………………………………………………………………………………………………………

                                           ARE YOU A WHEELCHAIR USER                      YES/NO

                                           DO YOU USE WALKING AIDS                            YES/NO                                                                       

              ANY OTHER PROBLEM ……………...…………………………………………………………

              Do you require any special care/attention prior to entry to water? If YES, what are these                        

              requirements?……………………………………………………………………………………….

 

              SIGNATURE OF APPLICANT, PARENT, OR GUARDIAN: …………………………………..

 

              AGREEMENT FROM MEDICAL ADVISER THAT THE ABOVE IS CORRECT AND THAT

              YOU MAY TAKE PART IN AN ORGANISED SWIMMING ACTIVITY.

 

             SIGNATURE OF DOCTOR:…………………………………………………DATE:………….…

 

             ADDRESS:…………………………………………………………………………………………

 

          Whilst the Club is affiliated to the Halliwick Association of Swimming Therapy, which is an expert body in the teaching of

          people with disabilities, by the Halliwick Method, we are unable to accept responsibility for loss or damage to person or

          belongings. Members joining must abide by the Rules of the Club.