Questionnaire – Lyme Splash

Add a Lyme Splash T-Shirt (£20 each)

T-shirts will be posted a few days after the event, price includes P&P

Add Raffle Tickets (£1 each)

Registration includes: Entry to Lyme Regis to Charmouth Challenge, a hot chocolate drink, biscuits & Rib Ride from our sponsors, swim hat, scan tag, a Lyme Splash badge for completion of the swim & a chance to win one of eight delicious prizes from Dorset Chocolatiers Chococo. Check out the shirts and raffle tickets

Instructions

For swimmer registration, please fill in the form below then click ‘Add to Basket’ at the bottom of the form and go through the checkout process to pay.

Part A: Pre-Entry Review/Assessment

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 months and are 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.

Yes
No
NA

Have you swum in open water in 2023?*

Yes
No

Have you complted a 2km or more swim in the last four months?*

Yes
No

How long (approximately) does it take you to swim 1 mile (in or out of competition)?*

Please give answer in minutes

If you answer “no” to the questions above you will be automatically precluded from participating. A participant must be able to swim a minimum of ONE MILE non-stop and have swum this in open water in the previous Four Months.

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?

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:

Have you 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 2023.
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

Firstname*

Lastname*

Date of Birth (dd/mm/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
Non-binary
Prefer not to say

Address

Street Address*

Address Line 2

Town/City*

County

Postcode*

Country*

Email*

Mobile Phone*

Emergency Contact*

Name and phone number to contact in an emergency

To ensure you are placed in the right wave to swim please indicate an approximate swim time for 2 miles / 3.15 kilometres in open water*

Please give answer in minutes

Opt-in

Can we use your details to email you about events & news?

Yes

Do you agree with our Terms & Conditions?*

Terms & Conditions can be found here: Click to see Terms & Conditions

Yes

Swim Registration

Instructions

Part A: Pre-Entry Review/Assessment

Part B: Pre-Challenge Fitness Review

Part C: Personal Information To Register

Address