4Strokes Swimming Academy UK

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0845 094 2855

Health Questionnaire

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Dear Academy Member,

This form is to be completed to help the 4Strokes team determine whether there are any special requirements/needs that should be taken into account to ensure all pupils receive the same dedication and experience during our swimming programmes.

NB This form must be completed by an adult for all members under the age of 16.

Please answer the following questions giving as much information as you deem necessary:





Your Name (required)

Your Child's Name (required)

Your Email (required)

Venue (required)

Day/Time of Lesson (required)

Does your child/Do you have any condition that can effectively be worsened by physical activity? (required)
 Yes No

Does your child/Do you suffer from any condition that can affect their/your breathing, for example Asthma, If so please provide information below on any treatment that may be required before, during or after physical activity. (required)
 Yes No

Please note here any medication/inhalers required: (Please ensure that inhalers are available for use during the swimming lesson if required).

If there are any other reason/needs that must be taken into consideration whilst your child/you are swimming then please ensure you give us as much information in order for the teacher to be completely aware and prepared for each and every pupil partaking in their lesson. If medical advice is required before you start an exercise programme then please ensure you seek advice from your Doctor. (required)
 Yes No

If yes, please make notes in the space below.

Declaration:
I herby confirm that the information given above is correct and true to the best of my knowledge and that I will ensure that where specified I will seek a doctors approval to undertaken a swimming programme with 4Strokes Swimming Academy UK Ltd. I will also ensure that all necessary medication is available to the person named below if required during their swimming lesson.

Parents/Members Signature: (required)