Active Aquatics Registration
Title
Mr
Mrs
Miss
Ms
Rev
Dr
Swimmers forename
*
Swimmers surname
*
Parent/Guardian Name (if appropriate)
Postcode
Address Line 1
*
Address Line 2
*
Address Line 3
*
Date of Birth (dd/mm/yyyy)
*
Email (a confirmation email will be sent to this email address)
*
Please confirm Email
*
Home Phone Number
Mobile Phone Number
Work Phone Number
Emergency Number
*
Swimmers Nationality
British
Irish
Other White
Indian
Pakistani
Bangladeshi
Other Asian
Black Caribbean
Black African
Other Black
White / Black Caribbean
White / Black African
White Asian
Other Mixed
Chinese
Other Ethnic Group
Please ensure that contact phone numbers supplied accept withheld numbers
*
This indicates mandatory fields