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Customer Registration
Please complete the form below and make payment to register for your Great Swim Local Wristband.
Account Details
First Name
*
Last Name
*
Email
*
Password
*
Confirm Password
Home Swim
*
Please select.
Derwent Reservoir Swim
Hadleigh Park Swim
Ragley Hall Swim
Sywell Country Park Swim
Personal Details
Postal Address
*
Address Line 2
Address Line 3
*
Postcode
*
Mobile Telephone Number
*
Home Phone Number
Gender
Male
Female
Ethnicity
Please select.
White British
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed Background
Indian
Pakistani
Bangladeshi
Any other Asian Background
Caribbean
African
Any other Black background
Chinese
Other
Undisclosed
White Irish
Any Other White Background
Disability
Please select.
None
Moderate Learning Disability
Severe Learning Disability
Physical Disability/Impairment
Hearing Impairment
Visual Impairment
Other/Not Specified
Registered Disabled
Health Impairment
Undisclosed
Date of birth
*
Swimming Ability
In the past week, on how many days have you done a total of 30 min or more of physical activity, which was enough to raise your breathing rate? This may include sport, exercise and brisk walking or cycling for recreation or to get to and from places, but should not include housework or physical activity that may be part of your job
*
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days
Before registering for Great Swim Local, how long had it been since you last went swimming?
*
Less than a week
Between a week and a month
1-3 months
4-6 months
1-2 years
3-4 years
5+ years
Never been swimming before
Which, if any, of the following types of swimming activity had you taken part in before these sessions? (choose as many as apply):
*
Lane swimming
Swimming classes/lessons
Swimming with children/teaching children to swim
General swimming (not in lanes)
Water fitness sessions (e.g. Aqua Aerobics)
Swimming outdoors
Other
None
Which of the reasons listed below, if any, describe your motivations for wanting to take part in Great Swim Local?
Please choose if applicable
Any physical health reason
To keep fit
To develop skills
Any enjoyment reason
Passion for open water swimming
To relieve stress/relax
To keep in shape/toned
To lose weight
Improve physical appearance
I enjoy the social side/meeting new people
I enjoy the competition/challenge
To improve my performance
To accompany friends/family
Its something we can do together as a family
Parents want you to be active
Helps with an injury/disability
Outdoor swimming is stimulating (environment)
For charity/fundraising
I was just inspired by Great Swim Local TV/Website/Social Media
Other
Emergency contact details
Emergency Contact Name
*
Emergency Contact Number
*
Alternative Contact Number
Emergency Contact Relationship to Swimmer
*
Acceptance
I accept the Great Swim Local
Terms & Conditions
*
Yes
No
I would like to receive SMS messages from Great Swim Local
Yes
No
I would like to receive emails from Great Swim Local
*
Yes
No
I would like to receive emails from Great Swim
*
Yes
No
I would like to receive emails from Great Swim Partners
*
Yes
No
I confirm that I have the ability to swim in open water
*
Yes
No