Booking Form Tue 05/01 18:00-18:50 (Minnows)

____________________________________________

Session date: *

Tuesday 05th January 18:00-18:50 (Minnows)

Booking Form and Health Survey to be completed by parents/guardians. Please be aware that; 1) the session may be streamed live via the HSC social media platforms and 2) the data collected in this form may be shared with Hartlepool Borough Council

Swimmer Name *

Please confirm they will be attending the swimming session *

Attending

Please be aware that each swimmer will be asked to complete a health survey prior to every session.

Swimmers must arrive 'Beach Ready' for the session and social distance guidelines (including adherence to the set allocated by the coach). Failure to adhere to guidelines will result in the swimmer being asked to leave *

Acknowledged and understood

Swimmers must be dropped off and collected promptly following the session (max 10 minutes following leaving the pool) *

Acknowledged and understood

Swimmers must bring the following equipment to the session and must not share equipment. - Full water bottles x2, swimming cap, goggles, swimming costume, towel, footwear and appropriate clothing to exit the building whilst still wet. *

Acknowledged and understood

Following the session it is recommenced that all equipment is thoroughly cleaned

The cost of the session is included within the monthly squad fee (£16pm). Please make payment via bank transfer - Sort Code: 05-09-75, Account Number: 12663108, Account Name: Hartlepool SC using the swimmers name as the reference *

Acknowledged and understood

Please be aware that if you cancel, you will still be charged for the session. The exception to this is is if the swimmer is experiencing COVID symptoms or is required to self isolate in line with government guidelines *

Acknowledged and understood

The questions below are from the Swim England Pre-training Covid-19 health screen *

Acknowledged and understood

The purpose of this screen is to inform and make you aware of the risks involved in returning to train

Have you had confirmed Covid-19 infection or any symptoms (listed) in keeping with Covid-19 in the last five months? 1) Fever, 2) New/persistent dry cough, 3) Shortness of breath, 4) Loss of taste or smell, 5) Diarrhoea or vomiting, 6)Muscle aches not related to sport/training *

If 'Yes', please provide details:

If 7 days post recovery and no symptoms then a gradual return to exercise is permissible but should persistent symptoms of breathlessness on exertion then you should consult your usual medical practitioner.

Have you had a known exposure to anyone with confirmed or suspected Covid-19 in the last two weeks? (e.g. close contact, household member) *

If 'Yes', please provide details:

Not allowed to train until they have self-isolated for 14 days.

Do you have any underlying medical conditions? (Examples include: chronic respiratory conditions including asthma; chronic heart, kidney, liver or neurological conditions; diabetes mellitus; a spleen or immune system condition; currently taking medicines that affect your immune system such as steroid tablets) *

If 'Yes', please provide details:

If you have an underlying medical condition that makes you more susceptible to poor outcomes with COVID-19 (including age >65) then you should consider the increased risk and may want to discuss this with you usual medical practitioner

Do you live with or will you knowingly come in to close contact with someone who is currently ‘shielding’ or otherwise medically vulnerable if you return to the training environment? *

If 'Yes', please provide details:

This is an individual call but awareness of risks and the appropriate precautions should be taken.

Do you fully understand the information presented in the Covid-19 Return To Training briefing and accept the risks associated with returning to the training environment in relation to the Covid-19 pandemic? *

If additional explanation required in this circumstance and if understanding is not forthcoming they should be advised not to train.

Able to train *

Sought Medical Advice *

Medical advice received *

If medical advice received, please provide a brief summary below

Please sign your full name to acknowledge the information provide is accurate *

If under 18, parent/guardian’s signature is required

Contact Number *

Website