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Pippies - Dicky Beach SLSC Inclusive Nippers Program Sign Up

Registration form for Dicky Beach Surf Life Saving Club's Inclusive Nippers Program 2025/26 Season
Participant Name*

First NameLast Name
Date of birth*

DayMonthYear
Date
Gender*
Parent Guardian (1)*

First NameLast Name
Relationship*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Contact Number - Parent / Guardian (1)*
Email*
example@example.com
Parent / Guardian (2)

First NameLast Name
Mobile Contact Number - Parent /Guardian (2)
Dietary requirements in case of catering
Do you give permission for the participant to be photographed?*

YESNO
Is the participant a member of Dicky Beach Surf Life Saving Club?*

YESNO
What dates will you be attending?

Saturday 11 October 2025 - 2.00pm - 3.00pmSaturday 8 November 2025 - 2.00pm - 3.00pmFuture dates to be advised
NEW PIPPIES ONLY - Please complete the following section if your child is a new participant.

We would love to find out more about the participant to best support them while in this program. Try and keep the answers tailored towards beach activities. Nb. It's not necessary to fill out every question, however the more information we have about the participant the better!
How does the participant mobilise? Eg. independently, wheelchair, crutches:
Does the participant have a diagnosis or condition/s?:
I like:
I dislike:
I become scared/upset when:
What calms me:
I communicate by:

Speaking/verbal communicationUsing Augmentative and Alternative Communication (AAC)Other
What I understand about the beach:
How can you help me understand:
I am sensitive to noise/sound?

YESNO
I do best when:
I am happiest when:
I like to be praised by:
What motivates me:
Is there anything you would like us to take into account when partnering a volunteer with your child? eg. Male/Female, Youth/Adult, One/Two carers:
Swimming ability - Freestyle distance:
Swimming ability - Dog paddle distance:
Swimming ability - How long can you hold your breath?:
Swimming ability - Can you tread water for 1 minute?

YESNO
Do you have any surf experience?
Is there any other important information you would like us to know about the participant?
Should be Empty:

Pippies - Dicky Beach SLSC Inclusive Nippers Program Sign Up