Channeling A Cause Swim Registration

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* 1. What is your first name?

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* 2. What is your last name

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* 3. Contact email

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* 4. Contact phone number

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* 5. If you are 16yrs old or younger, please provide name and consent from an authorised guardian

Name of guardian

Contact email of guardian

Phone number of guardian

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* 6. Which distance are you planning to swim?

1km

2km

5km

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* 7. Do you plan to join us at Bukit Merah on November 3rd after 4pm?

Yes

No, I'll swim at a different time at a location of my organising

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* 8. Would you like us to send you details of any up and coming swims we plan to host in the future?

Yes

No