Under Swim England Regulations and Technical Rules of Swimming.

Licence No 1EM230359

The eXcel Spring Qualifier Meet

Cash Entry Summary & Poolside Pass Application Form

Club ……Buxton & District SC………………………............

Contact Name ……Lance Davis…………................

Telephone Number ……07703 196010....................

Email address ………lance@buxtonswimmingclub.co.uk...............................

Individual Male Entries……………..@£12.50 each: Sub Total……………………………

Individual Male Entries……………..@£14.00 each: Sub Total……………………………

Individual Female Entries……………@£12.50 each Sub Total…………………………….

Individual Female Entries……………@£14.00 each Sub Total…………………………….

Individual Male Entries ……12…… @ £9.00 each: Sub Total ………108.00........

Individual Male Entries ……………… @ £12.00 each: Sub Total …………………….........

Individual Female Entries ……12.. @ £9.00 each: Sub Total ………108.00.........

Individual Female Entries ………….. @ £12.00 each: Sub Total ……………………..........

Poolside Passes Fri…………0………..@£10 per day: Sub Total……………………………..

Poolside Passes Sat ..………TBA....@ £20 per day: Sub Total …………………….........

Poolside Passes Sun ………TBA.... @ £20 per day: Sub Total …………………….........

Poolside Passes ……………TBA.... @ £35 For 3 days: Sub Total …………………….........

Total Cheque Enclosed: £ ......…………………..

For payment details please contact our treasurer pippa.hibbs@derventioexcel.org.uk.

Poolside pass DBS Information (passes will not be processed without this information) :-
Name Disclosure Number Position Date of Issue

Please return all completed entry forms, together with entry fees to: Steve Roome, 2 Battersea Park Way Derby DE22 4LT

Affiliated to Swim England East Midland Region and Derbyshire ASA