Lyme Splash Water Polo ChampionshipWater Polo Team Member Booking Please pay for your Team and then each team member needs to fill in this registration form. DO NOT USE THIS FORM ANY MORE Your team will be emailed a form to complete in advance of the event, this must be completed or you will not be able to play. PLEASE NOTE You must register and pay for a team first via the Team registration form.Add a Lyme Splash T-Shirt (£12 each)T-shirts will be posted a few days after the event, price includes P&PNo T-ShirtWomen XS 8Women S 10Women M 12Women L 14Women XL 16Women 2XL 18Men S 35/37Men M 38/40Men L 41/43Men XL 44/46Men 2XL 47/49Men 3XL 50/52Add Raffle Tickets (£1 each)No Tickets1 Ticket2 Tickets3 Tickets4 Tickets5 Tickets6 Tickets7 Tickets8 Tickets9 Tickets10 Tickets11 Tickets12 Tickets13 Tickets14 Tickets15 Tickets16 Tickets17 Tickets18 Tickets19 Tickets20 TicketsPART A: Pre-Entry Review/AssessmentCan you, swim, tread water and are happy out of your depth for over 6 minutes in the sea?* Are in a Water Polo team that plays currently or recently?* Team Name* PART B: Pre-Challenge Fitness ReviewHas your doctor ever said you have a heart condition (such as coronary heart disease, congenital heart disease or vascular heart disease)?* Yes No Do you feel pain in your chest, shortness of breath or dizziness when you undertake physical activity?* Yes No In the past month, have you had chest pain when you are not doing physical activity?* Yes No Do you lose your balance because of dizziness or do you ever lose consciousness?* Yes No Is your doctor currently prescribing drugs for blood pressure or a heart condition or do you take any medication that may affect you when taking part in physical exertion?* Yes No Are you pregnant?* Yes No Please can you indicate any disabilities?*We will do our best to accommodate any issues but in the interest of safety if we are unable to we will refund your entrance fee.Do you suffer from epilepsy?* Yes No Do you suffer from diabetes mellitus and need to take insulin?* Yes No Do you know of any other reason that may affect your ability to take part in physical activity?* Yes No ...If yes, please state why:Had COVID in the last 3 months and fit to swim*If you have had Covid in the three months before swimming and have been hospitalised or required oxygen please consult your doctor to confirm you are fit to swim and you will have needed to have swum at least 2k in open water before taking part. Had COVID in the last 3 maths and fit to swim. Yes No Not applicable Have you have answered YES to any of the questions in Part B?If you answered yes to any question in part B you will need to have a have a Medical Referee to confirm you are fit to take part in Lyme Splash 2019. Please download the form HERE If you have completed this form and sent/will be sending it please indicate how: By email By post PART C: Personal Information to Register (All information must be provided - this information will not be shared with third parties):Name* First Last Date of Birth* DD slash MM slash YYYY Under 18?If you are under 18 you will need consent from a Parent or Guardian Please download form HERE If you have completed this form and sent it please indicate how: By Email By Post Gender* Male Female Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Email* Mobile Phone*Emergency Contact*Name and phone number to contact in an emergencyTo ensure you are placed in the right league please indicate whether you are in the Splash League (beginners) or the Dash League (played recently or currently playing)*Opt-inCan we use your details to email you about events & news? Yes Terms & Conditions*By signing up I have read and accept the event terms and conditions. Read Terms & Conditions here Yes, I have read and accept the terms and conditions