Coaching Medical Questionnaire | Wild Swim Adventures

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Jurassic Coast Swimming

Wild Swim Adventures

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Swim Coaching Questionnaire

Please fill out the following form to help us understand your swimming ability & coaching requirements

First Name

Email Address

Last Name

Phone

Date of Birth

Emergency Contact Name

Emergency contact phone:

Are you currently on any medication?

No

Yes

Are you currently suffering from a medical condition, illness, or injury?

No

Yes

If you answered yes to any question, please elaborate

What is your current swimming ability?

I can swim 25m front crawl

I can swim 200m front crawl slowly

I am a competent swimmer, sub 6 mins - 200m

I am a strong swimmer, sub 3 mins - 200m

What open water swimming experience do you have?

Personal goals from open water swimming

Do you have any fears or anxieties about open water swimming?

Initials

Today's Date

I declare that the information I’ve provided is accurate & complete and I will notify Jurassic Coast Swimming of any changes

I confirm that if I have any symptoms or have come in contact with anyone with Covid-19 I will notify Jurassic Coast Swimming and will not attend swimming sessions

Thanks for submitting!

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