Name (in Full)
Date of Birth (dd/mm/yy)
Primary Contact Name
Is the Applicant a 'Non-Swimmer' or 'Novice Swimmer'?
Any ongoing medical conditions (Yes/No)?
Local Authority Lessons up to Level (e.g. Level 4)
Primary Contact Telephone
Swimming Instruction Class Achievement (e.g. 25 Metres)
Primary Contact Mobile
Emergency Contact 1 Name
Emergency Contact 1 Telephone
Emergency Contact 2 Name
Primary Contact Email
Emergency Contact 2 Telephone
Any form of disability (Yes/No)?
Can we use photos of your child on Club Website (Yes/No)
Do you consent to the terms below? (Yes /No)
 Applicant Details :
 Primary Contact :
We are required by Swim England Insurance to obtain 2 Contact Phone numbers.
 Emergency Contacts :
We are now also required by Swim England to obtain 2 Emergency Contact Names and Phone numbers.
These must be different from the phone numbers you have entered above!

 Applicant Swimming Ability :
 Applicant Medical :
 Photo/Video Use :
 Consent :
By submitting this form, I hereby give my consent to Birtley Amateur Swimming Club to store the personal data on this form and share the personal data with the affiliated bodies as outlined in the Clubs Information Security Policy and GDPR Statement. In addition, I give my consent to Birtley Amateur Swimming Club to store additional personal data relating to the management and development of the Swimmer named on this form and to share that information with the affiliated bodies. I consent to receive communications via email and SMS texts from Birtley Amateur Swimming Club relating to all Club matters.
I understand that I can request access to the personal data stored by Birtley Amateur Swimming Club and I can withdraw my consent at any time. I understand that on leaving the Club, unless otherwise requested, all peronsal data relating to the Swimmer named on this form will be retained by Birtley Amateur Swimming Club. Personal information of ex-members shall be retained (a) for the purpose of providing references, if requested, for the named Swimmer on this form (b) in the event that the Swimmer re-joins the Club in the future.

Download hardcopy Membership Form
I understand that by submitting this information/form online that it is my responsibility as the Parent/Guardian of the above child to ensure that any changes of address or swimming skills after submitting this application form are communicated to a Swimming Club Official. I accept that the Swimming Club will at reasonable intervals and upon request keep me informed of my child’s place on the Waiting List.

I also acknowledge the need to abide by the Club rules and accept responsibility of membership of the Club and all that it entails on behalf of the Named Applicant.

NOTE: The Club confirms that its Members, Instructors and Officials ALL agree to adhere to the Club Code of Conduct at all times.
I understand that in compliance with the Data Protection Act 1998, all efforts will be made to ensure that this information is accurate, kept up to date and secure and that it is used only in connection with the purpose and activities of the Club.