Clone of LLC Swim Enrolment Form

LLC Swim Enrolment Form - Term 2 2026

P: 9797 4000 | E: llc.swimming@harvey.wa.gov.au
How many students do you wish to enrol*

1 student2 students3 students4 students
Student 1 Details
Student 1: Name:*

First NameLast Name
Gender*

MaleFemalePrefer not to say
Date of Birth*

DayMonthYear
Last Certificate Awarded:
Achieved with:
Is the swimmer currently in school full time?*

YesNo
Are you currently swimming in our Term 1 Program?*

YesNo
Please provide details of any medical conditions/learning difficulties/social issues that may impact the student and/or attending parent?
Student 2 Details
Student 2: Name:*

First NameLast Name
Gender*

MaleFemalePrefer not to say
Date of Birth*

DayMonthYear
Last Certificate Awarded:
Achieved with:
Is the swimmer currently in school full time?*

YesNo
Are you currently swimming in our Term 1 Program?*

YesNo
Please provide details of any medical conditions/learning difficulties/social issues that may impact the student and/or attending parent?
Student 3 Details
Student 3: Name:*

First NameLast Name
Gender*

MaleFemalePrefer not to say
Date of Birth*

DayMonthYear
Last Certificate Awarded:
Achieved with:
Is the swimmer currently in school full time?*

YesNo
Are you currently swimming in our Term 1 Program?*

YesNo
Please provide details of any medical conditions/learning difficulties/social issues that may impact the student and/or attending parent?
Student 4 Details
Student 4: Name:*

First NameLast Name
Gender*

MaleFemalePrefer not to say
Date of Birth*

DayMonthYear
Last Certificate Awarded:
Achieved with:
Is the swimmer currently in school full time?*

YesNo
Are you currently swimming in our Term 1 Program?*

YesNo
Please provide details of any medical conditions/learning difficulties/social issues that may impact the student and/or attending parent?
Parent/Guardian Details
Full Name:*

First NameLast Name
Email Address:*
Phone Number (Home):
Phone Number (Mobile):*
Postal Address:*

Street Address

Street Address Line 2

City
Emergency Contact:*

First NameLast Name
Relation to Child:*
Phone Number (Mobile):*
Special Conditions
Do you consent to your child/ren's photo being used in the Centre's advertising?*

YesNo
Do you consent to your child's teacher using physical contact in the instruction of your child?*

YesNo
Please indicate your preferred lesson options (eg. days, times, same time as sibling):
Important information we should consider when assigning your child to a class:
If you have applied for a Kidsport voucher, please provide the voucher code:
Terms and Conditions

Click here to view the LLC Aquatics Terms and Conditions.
Declaration

I have read and agree to the Swim School terms and conditions of enrolment.
Signature*
Date:*

MonthDayYear
Date
Disclaimer:

The Shire of Harvey will not be responsible for any injury suffered by either participant or non-participant members of the group while using facilities: whether the injury be self-inflicted, caused by another member of the group, or caused by another person not associated with the group.

The Shire of Harvey will not be liable in any way for any loss of, or damage to the property of members of the group, whether members or non-members of the group cause the loss or damage.

The above does not apply to the extent that any injury, loss or damage is caused or contributed to by the willful negligent or other unlawful act of omission of the Shire of Harvey or any of its employees, officers, agents or contractors.
We are currently experiencing a high volume of enrolments.

Please allow 1 week for us to contact you regarding your enrolment.
Should be Empty:

LLC Swim Enrolment Form - Term 2 2026

Student 1 Details

Student 2 Details

Student 3 Details

Student 4 Details

Parent/Guardian Details

Special Conditions

Declaration