Disability Fund Application Form
Closing date: December 1
Swimmer Information
(to be completed by the swimmer or their representative)
Surname
*
Given name/s
*
Ethnicity
What is your gender?
Female
Male
Other
Date of birth
*
-
Day
-
Month
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Which region do you live in?
*
Please Select
Northland
Auckland
Waikato
Bay of Plenty
Taranaki
Hawke's Bay Poverty Bay
Manawatu
Wellington
Nelson Marlborough
Canterbury West Coast
Otago
Southland
Email
*
Phone
What is your disability type?
*
Physical
Intellectual
Vision
Hearing
Global Development delay
Health condition / medical
Nature of impairment/disability?
Parent or guardian's name
Applicant's relationship to swimmer?
What are you hoping to achieve through swimming/time in the water?
How many times do you swim per week?
Do you train with a coach or club?
Yes
No
I would like to
I used to
If yes, who/what club?
Can you swim 25m freestyle in deep water?
Yes
No
Do you compete or train in any other sport/s? If so, what sport/s?
Application Information
(and supporting documents)
What term/s are you applying for?
Term 1
Term 2
Terms 1 & 2
Term 3
Term 4
Term 3 & 4
Swim school provider name
Swim teacher name
Session setting and number of sessions (large group, small group, private)
Have you applied to Swimming New Zealand before?
Yes
No
Total cost
*
How many lessons will this help fund?
Attach quote
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of
Is a personal contribution possible?
Yes
No
Is this application for equipment?
Yes
No
What is the equipment and what is the intended use?
Cost of equipment
Attach quote
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of
Have you already purchased the equipment?
Yes
No
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dsf@swimming.org.nz
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