Connacht Regional Standard Claim Form

This form should be used by Clubs to inform the Connacht Region Swim Ireland where a swimmer has achieved the Connacht Regional Standard.

Claims should only be submitted by Clubs, on behalf of their swimmers.

Name:             ____________________________________   DoB:  _____________

Address:         ____________________________________

                        ____________________________________

                        ____________________________________   Phone: ______________

Email Add:     ____________________________________

Club:               ____________________________________

Event                          Time                Venue/Meet                           Date

1.____________         ____________            ________________    _______________

2.____________         ____________            ________________    _______________

3.____________         ____________            ________________    _______________

4.____________         ____________            ________________    _______________

We verify that the above information is correct:

Swimmer:         ________________________________

Club Secretary:________________________________

Dated:              ________________________________

This form should be forwarded to;

The Secretary, Connacht Region Swim Ireland,

M/S Breda O’Leary Garnafailagh, Athlone Co. Westmeath.

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