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Norbreck Primary Academy - Swimmer Ability Form
Please complete the following swimmer ability form as accurately as possible.
Swimmer Name
*
First
Last
My Swimmer is in Year
Please Select From Below
Year 4
Year 5
My Swimmer is in Class
Please Select From Below
Class - 4B
Class - 4F
Class - 40
Has Your Swimmer Had Lessons Before?
*
Yes
No
IF yes - Please select the most recent badge/stage they attained. If you can't remember or are unsure - please select 'Not Sure'
*
Not Sure
No badges received
Duckling 1
Duckling 2
Duckling 3
Duckling 4
Duckling 5
Stanley 1
Stanley 2
Stanley 3
Stanley 4
Stanley 5
Stanley 6
Stanley 7
Puffin Award
I CAN SWIM award
Stage 1
Stage 2
Stage 3
Stage 4
Stage 5
Stage 6
Stage 7
Stage 8
Stage 9
Water Skills 1
Water Skills 2
Water Skills 3
Water Skills 4
Water Skills 5
Water Skills 6
Octopus 1
Octopus 2
Octopus 3
Goldfish 1
Goldfish 2
Goldfish 3
Angelfish 1
Angelfish 2
Angelfish 3
Kingfisher 1
Kingfisher 2
Kingfisher 3
Shark 1
Shark 2
Shark 3
Dolphin 1
Dolphin 2
Bronze Award
Silver Award
Gold Award
Bronze Swimmer
Silver Swimmer
Gold Swimmer
5m
10m
15m
20m
25m
50m
100m
200m
400m
600m
800m
1000m
1mile
Is Your Swimmer Still Taking Part In Lessons?
*
Yes
No
If Your Swimmer Is No Longer Taking Part In Lessons, Please State How Long It Has Been Since They Last Took Part In Lessons
Leave Blank If Still In Lessons
Within the last 3months
Within the last 6months
Over 6months ago
Over 1year ago
Leave Blank if currently still in lessons
Has your swimmer ever had a negative experience of water/lessons or has any anxiety toward swimming lessons/water?
*
Yes
No
IF your swimmer has any anxiety or experienced negative situations in water/lessons please describe as accurately as possible your swimmer's experience and potential concerns you or they may have? Please leave blank if not applicable.
Medical considerations: Does your swimmer require medication or special considerations towards a medical condition which may be effected by exercise?
*
I am happy for my swimmer to attend swimming lessons beginning in 2025.
*
Yes
No
Parent/Guardian Email Address
*
Today's Date
*
DD
/
MM
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YYYY
