:: Qmotion Registration ::

Family
Registration Form

	Personal Info	ADULT 1

	Family Name	*
	First Name	*
	Date of Birth	*
	Gender	Male Female *
	Nationality	*
	Picture Upload

	Contact Info

	Address	*
	P.O Box	*
	City	*
	Mobile Number	*
	Home Telephone Number	*
	Office Number	*
	Office Email	*
	Personal Email (1)	*
	Personal Email (2)	*

	Medical Info	Please indicate if any health problems, physical disability or other concerns :

	Do you have a heart problem ?
	Have you ever had chest pains during exercising ?
	Do you have a low or high blood pressure ?
	Do you have a bone, back or muscular problem that may be aggravated by exercise ?
	Do you suffer from asthma or allergies ?
	Do you suffer from diabetes ?
	Are you pregnant or have you given birth in the past 3 months ?
	If any other, please mention here
*	If any of the above questions have been answered positively please provide a doctoral certificate that you are fit to exercise.

	Swim Level
Please indicate the level that fits best your profile : *

	Throw me in and we’ll meet at the bottom! (Beginner)
	600 to 1.000 meters in one hour? Take it easy, I’m not a pro (yet)! (Stroke Improvement)
	+1.000 meters in one hour? Stop it, you’re insulting me! (Advanced Swimmer)

	Emergency Contacts

	Family Name	*
	First Name	*
	Mobile Number	*
	Office Number
	Home Telephone Number	*

	Source	It would be great if you tell us of how you knew about us

	Choose one	*
	If others, please mention here

* Required fields