Missed Lesson Credit/Refund Request Form

Missed Lesson Credit/Refund Request Form
Full Name of Parent or Guardian:*

First NameLast Name
Contact Number:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:*
example@example.com
Student's Name:*

First NameLast Name
Class Day:*
Class Time:
Dates of Missed Classes:*
Missed Lesson Refund/Credit:*

Medical certificate supplied
Please upload any relevant Medical Certificates:

Upload a File
Please note that the maximum file size is 1024KB. It is preferred that a PDF version of your medical certificate is provided however, if you are experiencing trouble uploading a file, please try taking a photo and uploading as a JPEG. If neither of these options are successful, please contact our Aquatics Team via llc.swimming@harvey.wa.gov.au. Cancelof
Please state how you would like your money reimbursed:*

Credit on Links (LLC) account to be used for future programMoney to be reimbursed into your personal bank account (please note if the refund is less that $50, you will be issued petty cash. LLC will contact you to collect):
Please note:

Refunds under $50 will be paid through petty cash. Refunds over $50 are paid via bank transfer.

If the Account Holder Name is different to the name Leschenault Leisure Centre has listed as the "Responsible Person" for the child a phone call will be made to the Responsible Person for verification.
Account Holder Name:
BSB:
Account Number
Bank Name:
Terms and Conditions

Click here to view the LLC Aquatics Terms and Conditions.
I have read and agree with the Terms and Conditions above:*

Yes
Signature:*

Clear
Should be Empty: