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Conditions of Entry
Team or Individual Registration
Name of Swimmer
Organisation (if applicable)
Mobile phone Number
50% of my sponsorship money to go to:
How many other team members?
0 - just myself
Preferred Start time
Have you got a special reason for taking part?
If yes, would you be happy for your story to be used to help publicise the event?
Any special requirements, medical conditions or details for above questions
Please provide a name and contact number of someone who could be contacted in case of an emergency on the date of event
Emergency Contact Name:
Emergency Contact Phone number:
I have read and understand the rules of entry and understand that The Rotary Club of Buckingham is not liable in any way for my health and possessions before, during or after the event and that I participate at my own risk.
I am over 16 years old on date of event
If not, my application is being made by my parent or guardian
Parent / Guardian Name
Registration Fee Explained
£5 per individual, either pay for yourself only or group together and pay together
£5 for an individual
£10 for two people
£15 for three people
£20 for four people
£25 for five people
£30 for six people
Give a Custom Amount
Select Payment Method