Clone of KMSC Medical Questionnaire 2024

2024 - All club members must fill out the following Health Questionnaire annually. Please complete the form and submit upon paying your membership fees.
Name

First NameLast Name
Phone Number
Name of Emergency Contact
Emergency Contact Number
Medical Questionnaire
Has your doctor ever said you should avoid physical activity due to a medical condition?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pains when you were not doing physical activity?
Do you lose your balance because of dizziness, or do you ever lose consciousness?
Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?
Is your doctor currently prescribing drugs for your blood pressure or any heart conditions?
Do you know of any reason why you should not do physical activity?
Please list/describe any other health conditions you feel we should be aware of below.
Medical support notes: If you have answered YES to one or more questions, please contact your GP before starting swimming training, to ensure that is safe for you to do so. Should your health change, please inform the coach immediately and seek medical advice before continuing with training.
“I acknowledge receipt of the rules of Kenilworth Masters Swimming Club and confirm my understanding and acceptance that such rules (as amended from time to time) shall govern my membership of the Club. I further acknowledge and accept the responsibilities of membership upon members as set out in these rules.”

Club rules are available to view on the KMSC website.
I have read the statement above and confirm that all of the information provided is correct and I have no additional information I wish to share.

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Or upload your electronic signature here.

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Any information disclosed is maintained securely and will only be accessible to our coaches and specific coordinators and in accordance with data protection.
I have paid my club membership fees.
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2024 - All club members must fill out the following Health Questionnaire annually. Please complete the form and submit upon paying your membership fees.

Medical Questionnaire

Any information disclosed is maintained securely and will only be accessible to our coaches and specific coordinators and in accordance with data protection.