REQUEST FOR SPORT CLASS EVALUATION

Para-swimming sport class evaluation is provided by Swimming Canada to its members. If the request is for a para-swimmer who is a non-member requiring classification, they should contact Janet Dunn at jdunn@swimming.ca.

Swimmer's Last Name

Swimmer's First Name

Swimmer's Swimming Canada Registration Number

Gender

FemaleMale

Date of Birth *Please note swimmers must be 12 years or older to apply for level 2 and 3 status.

Day

Month

Year

Address

City

Postal Code

Province

Name of Swim Club

Home Phone

Cell Phone

Swimmer or Family Email

Coach Email

What is the nature of your request?

Level 1 (Development)Level 2 (Provincial)Level 3 (National)Review request

Please select the impairment that most affects your ability to swim.

Physical ImpairmentVisual Impairment/BlindIntellectual Impairment

Please state your diagnosis/impairment and any associated diagnoses/impairment.

Have you had any operations within the last two years, which may have an impact on your impairment and/or swimming ability?

YesNo

If yes, please give date(s) of operation(s), a brief overview and the consultant's discharge date.

Name of coach

Name of Parent or Guardian (if swimmer is under 18 years of age)

I can confirm that the above information is correct.

Yes

ClassificationEmail

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