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

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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