New Starter Medical Form | Little Swimming Co

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Parents Name

Date of Birth

Emergency Contact Name and Number

Swimmers Name

Phone Number

I agree to terms of serviceView terms

Please check any of the following that the swimmer may suffer from.

Eye Conditions or Injury

Ear and Hearing Conditions

Dental Problems

Severe Headaches of Migraine

Allergies

Respiratory and Asthma Conditions

Skin Conditions such as Eczema and Dermatitis

Heart Problems and Chest Pain

Dietary Problems

Fits, Convulsions, Epilepsy

Emotional Problems, Depression and Anxiety

Additional and/ or Sensory Issues

Physical Disabilities

Muscular or Skeletal Issues

Does the swimmer take any regular medication? Please leave further information in the comments

Yes

No

Thanks for submitting!

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