Swim School Membership Enrolment Form

Swim School Membership Enrolment Form
Contact Details
Responsible Adult Name*

First NameLast Name
Email*
example@example.com
Home /Mobile Phone*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Address*

Street Number and Address

Street Address Line 2

SuburbState / Province

Postcode
How did you hear about us?

FriendGoogleSocial MediaSchool
Are you wanting Adult Swim Lessons?*

YesNo
Are you wanting to book for:

Term ProgramHoliday Programor Both (Term and Holiday Program)
If you are a carer in a babies class, are there any medical conditions or previous experiences that may affect your participation in this program? (e.g. asthma, epilepsy, diabetes, near drowning or bad experience in the water)
Next of Kin Emergency Contact Details

Next of Kin/Emergency Contact should not be the same as the responsible person
Contact Name*

First NameLast Name
Relationship*
Relationship to the responsible adult (main contact)
Home/Mobile Phone*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.

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 Program

For Eligible Families
Surrey Park swimming are excited to share that we will cover the gap between the $200 “Get Active Kids” voucher and your lesson fees using our Community Access Program for Swimming (CAPS) Program (Term 4 2024 only!).

As a not for profit organisation, we value putting money back into our community and assisting those facing financial hardship. What is our Community Access Program for Swimming? Find out more here.

What is the “Get Active Kids” Program?

This Victorian Government initiative allows eligible Health Care Card and Pensioner Concession Card holders to apply for a Get Active Kid’s voucher of up to $200 to cover children’s swimming lesson fees with Surrey Park Swimming! The Get Active Kids voucher program aims to support families by getting their children involved in organised sport and to be active. Each eligible child can receive up to $200 in financial assistance for memberships and registration fees. Special considerations are provided for children in care services, those on temporary and provisional visas, international students and undocumented migrants.

You can apply for a voucher for each eligible child in your care. To check if you are eligible and to learn how to apply, please follow this link to the “Get Active Kids” voucher application process.

Round 8 applications opened at 10:00am on Wednesday the 9th of October until funds are exhausted. So get in quick to claim your voucher.

To redeem your voucher, please complete the above enrolment form and a member of our team will reach out to assist you with your child’s enrolment. We will also require a copy of your Get Active Kids voucher confirmation email to process your enrolment.

Terms and Conditions
1. Learn to Swim Victoria Provider Code: 3150998
2. The voucher will be redeemed upon enrolment with Surrey Park Swimming.
3. The voucher expires 29th April 2025.
4. The voucher can only be used for group class enrolments.
5. Non-attendance in a program does not entitle you to credits for the voucher
6. The Get Active Kids Voucher is not redeemable for cash. Vouchers are non-refundable and non-transferable.
7. For Term 4 2024 only, Surrey Park will cover the cost difference between the voucher and lesson fees. Enrolment is subject to lesson availability and until CAPS funds are exhausted.
NamesFirst NameLast Name
Are you using a Get Active Kids Voucher?

YesNo
Have you redeemed a Get Active Kids Voucher?

YesNo
Student 1

First NameLast Name
Get Active Kids Voucher Details

Voucher NumberVoucher Code
Please upload your Get Active Kids voucher

Cancelof
Student 2

First NameLast Name
Get Active Kids Voucher Details

Voucher NumberVoucher Code
Please upload your Get Active Kids voucher

Cancelof
Student 3

First NameLast Name
Get Active Kids Voucher Details

Voucher NumberVoucher Code
Please upload your Get Active Kids voucher

Cancelof

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:

Swim School Membership Enrolment Form

Contact Details

Next of Kin Emergency Contact Details

Student Details

Get Active Kids Voucher Program

What is the “Get Active Kids” Program?

Terms and Conditions