Gala Entry Form

Swimmers Name

GALA

ASA Reg. Number

Male / Female

Event
50m Freestyle
100m Freestyle
200m Freestyle
400m Freestyle
800m Freestyle
1500m Freestyle
50m Backstroke
100m Backstroke
200m Backstroke
50m Butterfly
100m Butterfly
200m Butterfly
50m Breaststroke
100m Breaststroke
200m Breaststroke
100m IM
200m IM
400m IM

Deventio 10th Open 9/10 April

Age as at:
31/12/2016
Entry Time

Total no. of Entries

Date of Birth:
LC

Achieved @

7.00

each

Coaches Pass (Contribution)

2.00

2.00

Barclays Bank Account

Sort: 20-09-72
Total

Account: 33006271
If payment is not received your entry will not be submitted
Please tick the box to certify that the above information, including entry
times, are correct to the best of your knowledge.
Payment to be made by direct bank transfer to the above account
Date of payment/reference
Contact email address
All forms to be returned by
22/02/16 No late entries accepted
Return by email to: pioneer79galasecretary@gmail.com
or
Return to competition box at Accrington Academy