CONFIDENTIAL
MEMBERSHIP CONTACT DETAILSFOR 2016-17
SWIMMER’S NAME: ______
DATE OF BIRTH: ______
Name of Mother: ______
Name of Father:______
Home address: ______
______
______
Post Code: ______
Home Tel No: ______
Email address (mother): ______
Email address (father): ______
Mobile No. (mother):______
Mobile No. (father): ______
Forms and fees to be returned to:
Hilary Idzikowska
Membership Secretary
Lisburn City Swimming Club
Lagan Valley LeisurePlex
LISBURN
BT28 1LP
Code of Conduct Annual Declaration
All Codes of Conduct are available on the Child Welfare pages on the Swim Ireland website:
They are also available on the member info page of the club website
The following declarations are to be signed annually by all members. They will be held by the Club Children’s Officer.
It is presumed that by submitting membership to Swim Ireland that every Club member has signed an appropriate code of conduct.
______
Young People:
I have read, understood and agree to abide by the Code of Conduct for Young People, Safeguarding Children 2010 and the Rules of Swim Ireland and Lisburn City Swimming Club.
Signature of Young person ______Date______
Please print name______
______
Parents/Guardians:
I have read, understood and agree to abide by the Code of Conduct for Parents/Guardians, Safeguarding Children 2010 and the Rules of Swim Ireland and Lisburn City Swimming Club.
Signature of Parent/Guardian ______Date______
Please print name______
Failure to sign the relevant code of conduct by will result in a member being refused entry to training.
Photography and Video Consent
Photographing/Videoing during Swim Ireland/Regional/Club events/training
Lisburn City Swimming Club request permission to use individual and group photographs and/or video footage for training, competition and/or promotional purposes.
This permission is sought on the basis that the Club will follow and adhere to the Swim Ireland photography and filming guidelines (Swim Ireland Guidelines for Safeguarding Children 2010 and any updates issued).
Attendance at a Swim Ireland or Club event may result in participants being photographed or filmed as part of the occasion, either as an individual or as a member of a group.
Participants may also appear in a photograph or video inadvertently.
All participants must accept this.
Parent/Guardian of Participant (if under 18):
I confirm that I give permission for my child to be filmed and/or photographed as part of
Swim Ireland/Regional/Club events and/or training
Signature:______
Parent/Guardian’s Name: ______
Date: ______
PLEASE RETURN THIS FORM TO THE MEMBERSHIP SECRETARY or A CLUB CHILDREN’S OFFICER - CCO
Health / Medical Form2016 - 17
This form is designed to find out about the current state of health of the participating swimmer, and any medication that is being taken. Its main purpose is to assist with medical attention, should it be required, so the information provided should be accurate and up to date.
ALL information provided will be held in the strictest confidence
Surname:______
First Name(s):______
Date of birth: ______
In the event of an emergency:
The coach / Team Manager should contact the following person:
Surname: ______
First name: ______
Relationship to swimmer:______
Tel No: (Daytime):______
(Evening):______
(Mobile):______
Please provide the name of the swimmer’s Family doctor (GP) and contact details
Doctor:______
Address:______
______
Tel No: ______
PLEASE RETURN THIS FORM TO:
THE MEMBERSHIP SECRETARY IF YOU ARE A NEW MEMBER, OR IF ANY OF YOUR DETAILS HAVE CHANGED SINCE SEPTEMBER 2016.
Health / Medical Form2016 - 17
1. Does he/she suffer from travel sickness, asthma, chest complaints, wheezing or hay fever, migraine, fits or faints, severe period pains, diabetes, nervous disorders, any other illness or disability. Yes/No
If yes, please provide full details: ______
2. Is he/she allergic to anything? (Antibiotics, particular foods or drugs etc..) Yes/No
If yes, please provide full details:
______
3. Does he/she have any special dietary requirements? Yes/No
If yes, please provide full details:
______
4. Is he/she receiving any medical treatment or taking any medication/drugs, whether prescribed, over the counter or homeopathic, at present? Yes/No
If yes, please provide full details of the ailment and how and when the medication/drugs are normally administered.
If you are on medication, you may need to obtain a THERAPEUTIC EXEMPTION FORM for competition. (Contact Swim Ireland for further details)
______
______
______
5. Has he/she had any contact with any infectious illnesses within the last month? Yes/No
If yes, please give details below:
______
Additional Information(Please delete as appropriate):
Are you registered disabled?yes / no
Do you have a sight disability? yes / no
Do you have a physical disability? yes / no
Do you consider yourself to have special needs? yes / no
Do you have specific medical needs? yes / no
Declaration:
The information I have supplied is accurate and correct.
I am in good health and have no medical conditions which prevent me from competing / training with LCSC - Lisburn City Swimming Club.
Name of swimmer:______
Signature of swimmer:______
Name of parent/ guardian: ______
Signature of parent/guardian: ______
Date:______
PLEASE RETURN THIS FORM TO THE MEMBERSHIP SECRETARY
FAILURE TO DO SO WILL RESULT IN A MEMBER BEING REFUSED ENTRY TO TRAINING