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
2 digit day, 2 digit month, 4 digit 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
Browse Files
Drag and drop files here
Choose a file
Cancel
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
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Have you already purchased the equipment?
Yes
No
©2023
dsf@swimming.org.nz
Preview PDF
Submit
Should be Empty: