Title
- Mr Miss Mrs Ms

First Name *

Surname *

Are you registering as an individual or as a team?
Individual
Team

Address *

City *

County

Post Code *

Phone *

Mobile

Email *

Gender *
Male
Female

Date of Birth (dd/mm/yyyy) *

How much do you aim to raise for people with spinal injuries?
£

At which pool will you do the ASPIRE Channel Swim? *

How did you hear about the ASPIRE Channel Swim? *
Swimming Pool Taken Part Before Weightwatchers magazine Zest Magazine Bodyfit Magazine Swimming Times Zoggs IVillage.co.uk Radio/TV Newspaper Rosemary Conley magazine Friend Aspire Literature Internet Women's Fitness Facebook Twitter Other

What is your motivation for taking part in the Aspire Channel Swim?
Keep Fit/Lose Weight Take part in a new challenge Raise money for Aspire Incentive prizes Other

Receive your Welcome Pack by email?
No Yes

How would you prefer to be contacted (please choose one)?
Email Post

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