Registration Form - D Swim Academy

* = required fields
SECTION A - STUDENT DETAILS
FULL NAME	*
IC NO / PASSPORT NO	*	SEX	MALE FEMALE
DATE OF BIRTH	/ / *	AGE	* YEARS
RACE	*

SECTION B - PARENT DETAILS (NOT REQUIRED FOR STUDENTS OVER 18 YEARS OLD)
FULL NAME	*
RELATIONSHIP WITH STUDENT	*	CONTACT PHN NO. 1	*
EMAIL ADDRESS	*	CONTACT PHN NO. 2
COMPLETE HOME ADDRESS	LINE 1 *
	LINE 2
	LINE 3

SECTION C - MEDICAL INFORMATION
IS THE STUDENT UNDER ANY MEDICATIONS? IF YES, GIVE DETAILS
DOES THE STUDENT HAVE ANY MEDICATION AND/OR GENERAL ALLERGIES? IF YES, GIVE DETAILS
ANY SPECIAL CONDITIONS THAT REQUIRE SPECIFIC ATTENTION? IF YES GIVE DETAILS

By submitting this registration form, I, myself or my parent/guardian has fully understood and agreed to follow the rules and regulations set by D Swim Academy Sdn Bhd (750654-V) and I, myself, or as parents/guardian of the student whose name is mentioned above hereby agree to release any and all claims, demands, losses, liabilities, indemnities and hold harmless the maker of any exercises the teachers / coaches / instructors and the companies involved. I verify that all the information given above is true and accurate.