Emergency Contact

Name of Athlete(Required)

First and Last Name

Personal Health Number(Required)

BC Care Card number or the PHN found on the back of your driver's license.

Name of Doctor

First and Last Name

Office Phone

Name of Emergency Contact(Required)

First and Last Name

Main Phone(Required)

Relationship:

Health Overview

Please provide any info you would like to provide for confidential files.

Allergies

Asthma (respiratory)

Blackouts / Fainting

Chest pain

Diabetes

Epilepsy

Hearing disorder

Heart condition

Headaches (recurring)

Seizures

Injuries

Physical limitations

Corrective lenses

Medications

Comments regarding checked items and other relevant info:

Phone

This field is for validation purposes and should be left unchanged.

Artistic (Synchronized) Swimming club for women age 19+. Beginner, intermediate and advanced. We swim from September through May.

HOME POOL:
Walnut Grove Community Centre Pool
8889 Walnut Grove Drive
Langley, BC V1M 2N7

| Artistic (Synchronized) Swimming for women age 19+ |