Trial Request

Swimmer Details

First Name

Known As

Last Name

Date of Birth

Gender

Please complete this extra information because the swimmer is under 18 - Phone number and email should also be for Primary Contact

Primary Contact Person

Relationship To Swimmer

Home Phone Number

Mobile Phone Number

Email Address

Retype Email Address

Address Line 1

Address Line 2

Address Line 3

Town/City

County

Postcode

Medical Details

Swimming Experience

Swims For Other Club

ASA Number

Please Select The Disciplines You Are Interested In

Life Saving

Masters

Swimming

Are You Human?