Sports Vouchers Plus
Government of South Australia
Office for Recreation, Sport and Racing
Claim up to $200
for children in Reception to Year 9
Child's information
First Name
First Name
Last Name
Family Name
First Name
Last Name
Child date of birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Gender Diverse
Is this the first time your child has joined this activity provider?
Yes
No
What is the cost to participate in this activity?
Has your child been identified as living with a disability?
Yes
No
Is English the main language spoken at home?
Yes
No
If no, what language do you speak at home?
Is your child from an Aboriginal or Torres Strait Islander background?
Yes
No
Medicare information
Medicare number
Reference number
Parent/Guardian information
First Name
First Name
Last Name
Family Name
First Name
Last Name
Street Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Suburb
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Postcode
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact number
Format: (000) 000-0000.
Email
example@example.com
An email notification may be sent to the above email address (assuming it is correct) advising the authorisation of the voucher used for your child
This voucher is for 1 X $100
OR This voucher is for 2 X $100
Note: 2 x $100 vouchers can be combined to put $200 towards one activity under the same provider. Alternatively, 2 x $100 vouchers can be split between two different providers where a maximum of $100 can be put towards each activity. Please indicate using the appropriate tick box above.
To be presented at an approved Sports Voucher Plus provider. To find a registered provider or for more information please visit sportsvouchers.sa.gov.au. Not redeemable for cash, only a reduction or refund of sport, active recreation or music tuition fees. Redemption value not to exceed 2 x $100. In presenting this voucher I give permission to the Sports Voucher Plus provider to share my information with the Office for Recreation, Sport and Racing (ORSR). The ORSR may share information to the Commonwealth Government for the purpose of validating the identity of a child with Medicare and with third parties (including research institutions or organisations) to improve the administration, outcomes or effectiveness of the program.
sportsvouchers.sa.gov.au
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