Swim School Membership Enrolment Form

Student Details
Student 1*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Gender*

MaleFemaleGender Non-Specific
Does this student have any medical conditions or previous experiences that may affect their participation in this program? (eg asthma, epilepsy, diabetes, near drowning or bad experience in the water) Please detail:
Student 2

First NameLast Name
Date of Birth

DayMonthYear
Date
Gender

MaleFemaleGender Non-Specific
Does this student have any medical conditions or previous experiences that may affect their participation in this program? (eg asthma, epilepsy, diabetes, near drowning or bad experience in the water) Please detail:
Student 3

First NameLast Name
Date of Birth

DayMonthYear
Date
Gender

MaleFemaleGender Non-Specific
Does this student have any medical conditions or previous experiences that may affect their participation in this program? (eg asthma, epilepsy, diabetes, near drowning or bad experience in the water) Please detail:

Get Active Kids Voucher
The Get Active Kids Voucher Program is helping families afford the cost of organised sport and recreation for their kids.

If you have a Get Active Voucher, please enter voucher number below and forward voucher to info@learntoswimvic.org.au

Get Active Voucher:

If you would like to find out about the program, eligibility, and offers please click here
If eligible and a current round of funding is open please use our Activity Provider code: 2931371
Provider Name: Surrey Park Swimming
Promotion Codes
If you have a promotional code, please enter it below.
Promotion Code:
Heidelberg Primary School
Due to our ongoing partnership with Heidelberg Primark School, we offer discounts to all HPS students
Are you Enrolled at Heidelberg Primary School?*

YesNo

Acknowledgement
I, First Name* Last Name*, hereby consent for myself/child/ren Names*, to attend the program at Learn to Swim Victoria. I understand that Learn to Swim Victoria shall be released from, and shall not incur, any responsibility or liability whatsoever for any accident or injury to the applicant or for any damage to or loss of property of the applicant. I hereby authorise Learn to Swim Victoria to organise medical or hospital treatment as they see necessary at my expense.

I acknowledge that my booking is a commitment to a full program of lessons. (Learn to Swim Victoria does not do makeup classes for any reason, including illness or holidays). I hereby consent to Learn to Swim Victoria collecting the health information as set out above.
Signature*

Clear
Date Signed*

DayMonthYear
Date
Should be Empty:

Acknowledgement