2024 Sports Vouchers

This voucher is for*

1 x $1002 x $100

Note:

2 x $100 vouchers can be combined to put $200 towards one activity under the same provider. Alternatively, 2 x $100 vouchers can be split between two different providers where a maximum of $100 can be put towards each activity. Please indicate using the appropriate selection above.

Child's Name*

Child first nameFamily name

Child's date of birth:*

Date

Gender:*

MaleFemaleGender diverse

Is this the first time {childsName} has joined this activity provider?*

YesNo

What is the cost to register for this activity?*

Dartmoor Costs - U9 $100 - U13 $165 - U16 $205

Has {childsName} been identified as living with a disability?*

YesNo

Is English the main language spoken at home?*

YesNo

If no, what language do you speak at home?

Is {childsName} from an Aboriginal or Torres Strait Islander background?*

YesNo

I will provide my child's:*

Medicare NumberAustralian Visa Number

Medicare number:

Child's Medicare Ref. no.

Number located by child's name on card

Australian visa number:

Parent/Guardian Name*

First nameFamily name

Street Address:*

Suburb:*

Postcode:*

Parent/Guardian Contact Number:*

Parent/Guardian Email:*

An email notification may be sent to the above email address (assuming it is correct) advising the authorisation of the voucher used for your child

To be presented at an approved Sports Voucher provider. To find a registered provider or for more information please visit www.sportsvouchers.sa.gov.au.

Not redeemable for cash, only a reduction or refund of sport, active recreation or music tuition fees. Redemption value not to exceed 2 x $100.

In presenting this voucher I give permission to the Sports Voucher provider to share my information with the Office for Recreation, Sport and Racing (ORSR). The ORSR may share information to the Commonwealth Government for the purpose of validating the identity of a child with Medicare and with third parties (including research institutions or organisations) to improve the administration, outcomes or effectiveness of the program.

2x $100 VOUCHER - 2025