Cottesloe SLSC
Bronze Medallion Course Enrolment Form
Section 1: Candidate Details
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Day
-
Month
Year
Date
Emergency Contact Name
*
Emergency Contact Phone
*
Parent's Name (Candidate Under 18 years of Age)
Parent's Contact Phone
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Section 3: Prerequisites and Declaration
SLSA Membership - I confirm I have applied for or renewed my membership with Cottesloe SLSC for the current season.
*
Yes
Please confirm if you have paid your course fee with the office.
*
Yes
No
Other
Age Requirement - I confirm that I will be at least 15 years of age on or before the final assessment date.
*
Yes
No* - confirm with the Education Officer if you may be permitted to commence training
Prerequisite Swim Test (400m)
You must complete a 400-metre swim in a pool, or in a calm open water venue in under 9 minutes. This test must be completed prior to the first water session. (Completing formal evidence)
I have completed the swim test
*
Yes - please provide written evidence, with a certificate signed by a qualified Swimming Instructor, or SLS Assessor. Swim verification certificates available from the CSLSC office or via email from the Education Officer: education@cottsurf.com
No - contact the Education Officer to discuss: education@cottsurf.com
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Section 4: Medical Declaration
The Bronze Medallion course is physically demanding. SLSA requires a medical declaration. Please tick the appropriate box for each statement:
Medical Questions
*
Rows
Yes
No
Do you suffer from any heart condition, high blood pressure or chest pain?
Do you suffer from asthma, fainting, fits or dizzy spells?
Are you currently taking any form of medication for your health
Have you had any serious injury, major surgery or do you suffer from any other conditions which may impact your ability to do this training?
Are you allergic/ Anaphlatic to anything?
Do you have a learning and or speech impairment?
If you answered yes to any of the above, please provide details here:
Section: Emergency contact
This section must be completed if the candidate is under 18 years of age.
*
Rows
Guardian/parent 1 details
Guardian/parent 2 details
Full Name
Relationship to candidate
Mobile phone
Email address
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Members Consent
If the Candidate is under 18 years of age, please also consent on their behalf.
Code of Conduct and Rules
*
I, the candidate, agree to abide by the rules, regulations, and codes of conduct of Surf Life Saving Australia (SLSA), Surf Life Saving Western Australia (SLSWA), and the Cottesloe Surf Life Saving Club (CSLSC). I understand that failure to adhere to these standards may result in my removal from the course.
Photo Consent
I, the Candidate (and/or Parent/Guardian), consent to being involved in media that may be used for purposes including, but not limited to, the advertising and promotion of current or future courses through various channels such as newsletters, websites, and social media platforms.
*
I do give consent to beginning involved in future and current advertising and promotion.
I DO NOT give consent to be involved in this process.
Candidate Signature
*
Parent/Guardian Signature
Date Signed
*
-
Day
-
Month
Year
Date
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Parental / Guardian Consent ( Under Age of 18 years)
Guardian confirmation
I, the undersigned Parent/Guardian, confirmation that I have legal guardianship of the candidate named in Section 1 and grant the following permissions:
A. Candidate Participation in Course
I consent to my engaging in training with Cottesloe SLSC.
I do NOT consent to engaging in the training.
B. Lunch Break Consent
I consent to my child leaving the club premises unsupervised during scheduled lunch/rest breaks.
I do NOT consent to my child leaving the premises; they must remain in a designated supervised area at the club during all breaks.
C. End of Session Departure - please select the approved method for the candidate to leave the club grounds immediately after a training session:
Independent departure
Parent/guardian pick up only
Depart with Approved Person
Parent/ Guardian Name
First Name
Last Name
Parent/Guardian Signature
Date Signed
-
Day
-
Month
Year
Date
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Submit
Submit
Should be Empty: