Polo – Team Bookings

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&P

Add Raffle Tickets (£1 each)

PART A: Pre-Entry Review/Assessment

Can 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 Review

Has 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*

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

Email*

Mobile Phone*

Emergency Contact*

Name and phone number to contact in an emergency

To 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-in

Can 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

Lyme Splash Water Polo ChampionshipWater Polo Team Member Booking

DO NOT USE THIS FORM ANY MORE

PLEASE NOTE

PART A: Pre-Entry Review/Assessment

PART B: Pre-Challenge Fitness Review

PART C: Personal Information to Register