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Yass Valley Swimming Lessons Registration

2019/2020 Season

5 Lessons (1 lesson per week-after school) - $ 72.00

18 November 2019 – 19 December 2019

Preferred Day: Monday Tuesday Thursday

Intensive - Monday – Friday - $72.00

Wk1 - 6 January 2020 – 5 days - Yass -

Wk2 - 13 January 2020 – 5 days - Yass Binalong

Wk3 - 20 January 2020 – 5 days - Yass -

Parent/Carer Details

Name: Surname:

Address:

Home Phone: Work Phone:

Mobile Phone: Email: Emergency Contact Details:

Name: Surname:

Relationship:

Address:

Home Phone: Work Phone:

Mobile Phone: Email: Child Details: Name: Surname:

D.O.B: Medical Information: Please list Medical Conditions and Allergies This information will only be accessible by authorised individuals

Asthma

Diabetes

Epilepsy

Anaphylaxis

Other __________________________________________________________________

I give permission for Yass Valley Council to use photographs for advertising for swimming lessons purposes

Please Complete Swimming Assessment Questionnaire over page

Please note – Lodgement and payment of this application should be made directly to the Staff at the Yass Swimming Pool

52(b)

Page 2 of 2 Document No: 52(b) Created:07/09/2017 Review date: 07/2019

Version No: 1 Author: Facilities Coordinator Doc Type: 27

File Name:Yass Valley Swimming Lessons App Approved By: Director of Engineering

Yass Valley Swimming Lessons Registration

2019/2020 Season

Swimming Assessment Questionnaire

My child can put their face in water and blow bubbles My child can put their head under the water and blow bubbles My child is happy to float on their back with support My child can swim Freestyle for 5m across the pool My child can swim Backstroke for 5m across the pool My child can swim Breaststroke for 5m across the pool My child can swim Butterfly for 5m across the pool My child can swim all 4 strokes with form for 15m My child is happy to enter deep water My child can dive in deep water

I/we understand and agree to abide by the rules and regulations set out in the Yass Memorial Pool Operations Manual and enforced by Yass Valley Council lifeguards. All information collected will only be accessible to authorised individuals.

Signed Date Paid

Office use only: Rec No: ________________ Amount Paid ________________ Signature ________________

Day / Week: ___________

Time: ___________