Student Name: __________________________________________________________________________
Family name
First name
Parent/Caregiver _________________________________________________________________________
Address: _______________________________________________________________________________
Phone:______________ Mobile: ___________________ Email: ___________________________________
Student Gender: M □ / F □
Age: __________________________ DOB: ____________________
Central Swim School sets classes by ability. Please indicate if your child can do the following:
Full face submerge
Blow bubbles
Float on front
Float on back
Kicking in streamline position on front
Kicking in streamline position on back
Freestyle arms
Backstroke arms
Freestyle breathing
Freestyle in deep water
Backstroke in deep water
Other strokes
Y□ / N □
Y□ / N □
Y□ / N □
Y□ / N □
Y□ / N □
Y□ / N □
Y□ / N □
Y□ / N □
Y□ / N □
Y□ / N □
Y□ / N □
Y□ / N □
Does your child have any special needs?
(please detail so we can best assess needs):
Y□ / N □
Preferred Day:
Monday □
Tuesday □
5-8 metres
5-8 metres
5-8 metres
5-8 metres
10-18 metres
25 metres
25 metres
Wednesday□
Thursday □
Y□ / N □
Y□ / N □
Y□ / N □
Y□ / N □
Y□ / N □
Y□ / N □
Y□ / N □
Friday □
Saturday □
(Please tick)
Where:
Cromwell Swim Centre □
Molyneux Aquatic Centre □
(Please tick)
Preferred programme:
(Please tick)
Learn to Swim
Programme □
Holiday Programme □
Water Safety
Programme □
Note: If you find you are unable to attend the Term/Holiday classes that you have enrolled for please advise
us by email to [email protected]. Note this must be done before the beginning of the
Term or before Holiday classes start, or a booking fee of 25% of the class fee may be charged.
Do we have permission to use digital images for the purpose of advertising or promotional material? Yes
No □
For more information or queries please contact 03 440 0680 or email [email protected].
Parent Signature _______________________________________________
Central Otago Swim School Vision Statement:
Every person in our community can swim with confidence.
□