School Holiday Swim Program Enrolment Form

Parent/guardian details

First name

Last name

Address

Town

Postal Code

Best contact number

Email address

How did you hear about us?

Student 1 details

First name

Last name

Date of birth

Medical condition and medication details

Has your child previously participated in a swimming program?

Yes

No

Where did they attend the swimming program?

Last term student was enrolled (term, year)

Highest swimming program level achieved?

Select the swimming skills this student can complete

Questions	N/A	5m	10m	15m	25m
Swim on front (eg doggy paddle)	N/A	5m	10m	15m	25m
Swim on back (lay on back kicking and arm action)	N/A	5m	10m	15m	25m
Freestyle	N/A	5m	10m	15m	25m
Backstroke	N/A	5m	10m	15m	25m
Breaststroke	N/A	5m	10m	15m	25m

Select the skills that this student can complete

Float on back unassisted

Jump into the water, turn and return to edge unassisted

Add another student to this form

Student 2 details

First name

Last name

Date of birth

Medical condition and medication details

Has your child previously participated in a swimming program?

Yes

No

Where did they attend the swimming program?

Last term student was enrolled (term, year)

Highest swimming program level achieved?

Select the swimming skills this student can complete

Questions	N/A	5m	10m	15m	25m
Swim on front (eg doggy paddle)	N/A	5m	10m	15m	25m
Swim on back (lay on back kicking and arm action)	N/A	5m	10m	15m	25m
Freestyle	N/A	5m	10m	15m	25m
Backstroke	N/A	5m	10m	15m	25m
Breaststroke	N/A	5m	10m	15m	25m

Select the skills that this student can complete

Float on back unassisted

Jump into the water, turn and return to edge unassisted

Add another student to this form

Student 3 details

First name

Last name

Date of birth

Medical condition and medication details

Has your child previously participated in a swimming program?

Yes

No

Where did they attend the swimming program?

Last term student was enrolled (term, year)

Highest swimming program level achieved?

Select the swimming skills this student can complete

Questions	N/A	5m	10m	15m	25m
Swim on front (eg doggy paddle)	N/A	5m	10m	15m	25m
Swim on back (lay on back kicking and arm action)	N/A	5m	10m	15m	25m
Freestyle	N/A	5m	10m	15m	25m
Backstroke	N/A	5m	10m	15m	25m
Breaststroke	N/A	5m	10m	15m	25m

Select the skills that this student can complete

Float on back unassisted

Jump into the water, turn and return to edge unassisted

Emergency contact

First name

Last name

Best contact number

Relationship to child

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The personal information requested on this form is being collected by Council for the purpose of enrolling you and/or your child/ren as an aquatic education participant in the Latrobe City Leisure Facilities swim program. The personal information you provide will be used solely by Council for that primary purpose or directly related purposes.

The information relating to any health issues is required so the staff will be able to give you and/ or your child/ren the best support available. This information will be used solely by Council for that primary purpose or directly related purposes.

If you choose not to provide this information, then we will be unable to process your application. The applicant understands that the personal and health information provided is for the reasons outlined above and that he or she may apply to Council for access to and/or amendment of the information. Requests for access and/or correction should be made to the Privacy Officer of Latrobe City Council on 1300 367 700.

×

Parent / Guardian Declaration

As parent/ guardian of all the students listed above, I give consent for their participation in the Aquatic Education Program. I agree to delegate authority to the staff members and instructors involved. Where it is impracticable to communicate with me, I authorise the person in charge, in the event of any illness or accident, to obtain on my behalf any such medical assistance as my child/children may require and I agree to bear any cost thereby incurred.

I understand, as parent/ guardian, that it is my responsibility to present my child/ren to their appropriate instructor at the commencement of each lesson and also be present on pool deck to collect my child/ren at the end of each lesson.

I agree to pay all program fees before the first session and understand that if I do not do this, my child will lose their position in the program. Any outstanding fees will be passed onto a debt collection agency.

If my child is unable to attend one of the sessions I understand no refund is available, and a free visitor pass for a child swim will be provided

I further acknowledge that I agree that neither the Latrobe City Council, nor it’s officers and servants, will be liable for any damage, loss or injury how so ever caused or of what so ever nature that may be incurred by my child/ren in attending the venue or activities in the said program.

I have read and accept the above conditions

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