Swimmers Name GALA

Age as at: Date of Birth:31/12/2016

Male / Female Event Entry Time LC Achieved @

800m Freestyle

1500m Freestyle

Total no. of Entries 12.50 - each

Coaches Pass (Contribution) 1 2.00 2.00

If payment is not received your entry will not be submitted

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

-

Please tick the box to certify that the above information, including entry

times, are correct to the best of your knowledge.

Barclays Bank Account

Sort: 20-09-72

Account: 33006271Total

Gala Entry Form

Stockport 1 April 2016

ASA Reg. Number