ASA Agatha Christie Sea Swim Sunday 19th September 2010 12.30pm and 2.30pm
Your personal details:‐ Title:
First Name:
Surname:
Address:
Post Code:
Telephone No:
Date of Birth:
Gender: (please tick) Male
Female
Age on day of swim: (please tick) *14‐16
16‐25
25‐35
35‐45
45 & over
*A signed hard copy of this form will need to be sent to acknowledge parental/guardian consent
Email:
Mobile No:
How did you hear about this event?
Event specifics: Do you consider yourself to be a competent swimmer?
Medical conditions (please state):
Current medication (please state):
On the day emergency contact details: Contact name:
Relationship:
Home number:
Mobile number:
Please tick this box if you would like to help even more by raising sponsorship
If you would like to set up an online sponsor page log onto www.virginmoneygiving.com, search ‘Devon Air Ambulance Trust’ and once on our homepage click ‘events’ on the left hand side and select the ‘ASA Agatha Christie Sea Swim’ button. Alternatively to set up a page on www.justgiving.co.uk again search ‘Devon Air Ambulance Trust’ and follow the instructions on screen to set up your page/account.