Name *

First Name

Last Name

Gender *

Male

Female

Other / Prefer not to say

Name of Parent/Guardian (Required if swimmer is under 18)

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Has anyone ever told you that you have a heart condition and that you should only do physical activity as recommended by a doctor? *

Yes

No

Do you ever feel pain in your chest when NOT doing physical activity? *

Yes

No

Do you ever feel faint or have spells of dizziness? *

Yes

No

Have you ever been told you have high blood pressure? *

Yes

No

If yes, is your blood pressure currently controlled within normal limits?

Yes

No

Is there anything else you feel is important I should know in regard to you taking part in this activity? (e.g. getting in or out of the water, mental health, barriers to learning) *

Yes

No

Do you have any health concerns e.g diabetes and especially those which could be made worse by exercise, cold water? E.g. Reynaulds, asthma etc. (please give details) Are you currently taking any medicines or alternative remedies which I should be made aware of? (please give details) *

Yes

No

Fit to participate *

I certify that I am physically fit to take part in these sessions and have not been advised otherwise by a medical person. I acknowledge the inherent dangers of cold, open water swimming. I will keep DCT up to date with any changes in my health which could affect my participation and that of others.

Emergency contact name *

First Name

Last Name

Terms of Participation *

You understand that whilst and enjoyable and worthwhile sport, swimming in open water can be dangerous, can result in injury or death and should only ever be undertaken after you have first satisfied yourself that you/the Swimmer are medically fit to undertake all training that you/the Swimmer will or might undertake and that you/the Swimmer are doing so in a safe area and in appropriately safe conditions (“Your Checks”). By participating in any training with the Dover Channel Training the Swimmer is representing that the Swimmer/you as the parent/guardian for the Swimmer, have first conducted Your Checks. Dover Harbour is recognised as an appropriate location for swimming, particularly those training for marathon swims like the English Channel. Dover Harbour Board has designated by coloured buoys a significant area along the shoreline giving priority to the public for the purpose of swimming - see www.doverport.co.uk for details of the designated area and its supervision/regulation. Any question or concern you may have about swimming activities in this area should be addressed to Port of Dover and by signing this Declaration you the undersigned (and, where the Swimmer is under 18, on behalf of the Swimmer also) unequivocally accept that it is your express responsibility to properly familiarise yourself with, and to remain within, the areas which the Port of Dover has designated as being safe for the time and duration that you propose to swim on each and every occasion. Whilst the Dover Other training locations used from time to time have also been assessed as suitable for training. Dover Channel Training Group does its best to relay its current understanding as to such areas, that information is conveyed without any liability to do so and on the express basis that you will always independently satisfy yourself as to where and when it is safe to swim. The Dover Channel Training Group does not form part of a coaching service for swimmers and comprises and is led by volunteers without formal medical or health and safety qualification or training, who offer support or guidance on a personal and informal basis without obligation to do so or responsibility for doing so to a standard of care, or to any standard at all. You/the Swimmer understand that you/the Swimmer are/is free to disregard any support, assistance or guidance at any stage and that to accept or rely upon any support, assistance or guidance is undertaken solely at your/the Swimmer’s own risk. No safety cover is provided by the Dover Channel Training Group for any swimmers and the Dover Channel Training Group does not obtain and maintain any insurance for any risks for the benefit of swimmers or beach-goers. You/the Swimmer are strongly advised to ensure that your own safety cover and appropriate insurance is obtained before undertaking any swimming or other training with the Dover Channel Training Group.

I have read and agree to the Terms of Participation

Declaration *

I declare that I understand and accept for myself as the Swimmer or (if my child is the Swimmer) for myself and my child named above, that: 1. The Swimmer has a settled intention to conduct open water swimming training regardless of any advice, encouragement or arrangements that might be provided by the Dover Channel Training Group. 2. I understand and accept that any information, guidance and/or assistance which is offered by the Dover Channel Training Group in relation to: a) the operation, participation within or conducting of any training activity associated in any way with the Dover Channel Training Group, b) the risk to health or safety of swimmers and any other persons, c) the security or condition of any belongings, or d) any other matter or for any other purpose or reason connected with the swimming plans of swimmers or activities associated with the Dover Channel Training Group is provided freely without commitment and without obligation to provide the same whether pursuant to a duty of care or to any standard or at all, and further I understand that is relied upon/accepted by me/the Swimmer at my/the Swimmer’s sole discretion and entirely at my/the Swimmer’s own risk; 3. it is solely incumbent on me to continually assess and appropriately respond to the ongoing risks to the health or safety of me/the Swimmer during and after all swimming or other training at Dover Harbour and at all times to act responsibly when open water swimming with the Dover Channel Training Group 4. any personal data (other than medical data, which will be used as stated above) supplied by me to the Dover Channel Training Group, may be retained and used freely by the Dover Channel Training Group to assist them with the provision of marathon swimming information, guidance and assistance to me or (if appropriate) me and my child. 5. I have carefully assessed the competence and responsibility of myself/the Swimmer and deem it sufficient for the purpose of carrying out training of the type and duration that might be carried out with the Dover Channel Training Group without requiring any assistance or monitoring from the Dover Channel Training Group. 6. I have read, understand and agree with the Terms of Participation as set out above.

I have read and agreed to the declaration

Confirmation *

By signing this form, I certify that I have read and understood it as well as the importance of it. I also declare that the information I’ve provided is accurate and I give the Declaration as stated above on the understanding as set out in the Terms of Participation

Social Media *

DCT takes photos of training sessions to enable a photo diary of your training. These photos may appear on DCT or Run Surrey Hills website, on social media and on our blog posts which are distributed by email. If you do not wish to be in photos, please ensure you position yourself accordingly and / or bring it to the attention of the beach crew.