Swimming Race Registration Form

Registration Form - 200M Relay Swim

For Organ Donation Awareness & Unity in Diversity - EVERYONE OVER 18 CAN REGISTER
QUALIFIER 100M TIMED SWIMS 4 Lengths of the Pool (1/2 Derby)

May 8th to 14th - Aura Leisure Centres Nationwide*

* Ducky Deed will pre-arrange a date and time that suits you to do your individual timed swim

---------------------------------------------------------------------------

DERBY - 30 Fastest individual swimmers from the nationwide timed swims, will then be invited to compete in the 200M Derby (2 rounds of 4 lengths of the pool). Mixed teams will be formed on derby day Sunday 21st May, in Aura Leisure Navan, Co Meath

*PRIZE* - 1 Year's Family Membership at Your Local Aura Leisure Centre (Non Transferable / Non Redeemable)
Applicant Information

Derby Is Open to Everyone over 18
Full Name*

First NameLast Name
Date of Birth*

DayMonthYear
Please Type
Gender*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityCounty

Eircode
Emergency Contact Person*

First NameLast Name
Emergency Person Phone Number*

Area CodePhone Number
Relationship to Emergency Contact Person*
Organ Recipient / Donor Status

Teams will also include an Organ Recipient and a Member of a Deceased Donor Family
1) Organ Recipient*
2) Member of a Deceased Organ Donor Family*
Terms/ Waiver/ Release
I am over 18I am in good shape, health, and conditionI will follow the rules and regulations of the race eventI can be contacted to arrange an appointment for my individual qualifier timed swim. Fastest 30 individuals qualify to participate in the DerbyI am available to participate in the Derby race on Sunday 21st MayI don't have any medical condition or medical history that will be affected if I participate in this eventI acknowledge that this race requires physical activity and there are possible risks and dangerI release the race event organizers from any responsibility in case of an accident, illness, or injuryI allow taking my photos and videos which can be used for the event portfolio or advertisingI confirm that all information in this registration form is accurate and true
Participant's Signature*

Powered by Jotform SignClear
Date Signed*

DayMonthYear
Please Type Date
Should be Empty:

Registration Form - 200M Relay Swim

Applicant Information

Organ Recipient / Donor Status

Terms/ Waiver/ Release