Southeastern Swimming

Information Form for Disabled Swimmers

Name: ____________________________________ Age: _________Date of Birth:_____________________

Address: ___________________________________________Phone number: ________________________

Events Entered:

Event

No.

Event

No.

Event

No.

Event

No.

Type of disability (describe):_________________________________________________________________

_________________________________________________________________________________________

Extent of disability (Be specific, e.g., totally or partially blind, totally or partially deaf, loss of one or more limbs, multiple disabilities etc.): _________________________________________________________________________________________

_________________________________________________________________________________________

The following persons will accompany the swimmer for any needed assistance:

_________________________________________________________________________________________

Seizures? Yes __________ No ________ Are You on Medication? Yes ___________

Type of Medication

Dose

Parent or Guardian’s Name: __________________________ Phone No.:__________________

Parent or Guardian’s Signature:____________________________________________________

Athlete’s Signature: _____________________________________________________________

Physician’s Name: _________________________________ Phone No.:___________________

Physician’s Address:_____________________________________________________________

I have examined the above entrant and, in my opinion, there is no mental or physical reason why he
or she should not participate in USA Swimming competition.

Physicians Signature: _________________________________ Date: _____________________