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Swim School Enquiry
Like to know more about Elixr's Swim School?
Fill in your details below and we will be in touch.
Parent/Guardian
First Name of Parent/Guardian*
Last Name of Parent/Guardian*
Contact number*
Contact email*
Child 1
First Name of Child*
Last Name of Child*
Date of Birth*
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Age:
Years*
Select One
0
1
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5
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14
Months*
Select One
0
1
2
3
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5
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Preferred time and day*
Child's ability:
Age specific questions:
2.75 years - 5 years
Does your child usually wear a floatie / puddle jumper / back float or something similar?
Select One
Yes
No
Does your child put their face in the water / bath / shower?
Select One
Yes
No
Can your child swim unassisted without a floatie / puddle jumper / back float or something similar?
Select One
Yes
No
Primary School Age 5+
Does your child attend primary school?
Select One
Yes
No
Can your child swim unassisted, without a floatie / puddle jumper / back float or something similar?
Select One
Yes
No
What distances does your child regularly swim?
If your child is over 7 can they swim breaststroke and butterfly?
Select One
Yes
No
After completing the above is there anything more you feel we should know?
General Comments:
Child 2
First Name (Child 2)
Last Name (Child 2)
Date of Birth (Child 2)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
January
February
March
April
May
June
July
August
September
October
November
December
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Age:
Years (Child 2)
Select One
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Months (Child 2)
Select One
0
1
2
3
4
5
6
7
8
9
10
11
Preferred time and day (Child 2)
Child's ability:
Age specific questions:
2.75 years - 5 years
Does your child usually wear a floatie / puddle jumper / back float or something similar? (Child 2)
Select One
Yes
No
Does your child put their face in the water / bath / shower? (Child 2)
Select One
Yes
No
Can your child swim unassisted without a floatie / puddle jumper / back float or something similar? (Child 2)
Select One
Yes
No
Primary School Age 5+
Does your child attend primary school? (Child 2)
Select One
Yes
No
Can your child swim unassisted, without a floatie / puddle jumper / back float or something similar? (Child 2)
Select One
Yes
No
What distances does your child regularly swim? (Child 2)
If your child is over 7 can they swim breaststroke and butterfly? (Child 2)
Select One
Yes
No
After completing the above is there anything more you feel we should know?
General Comments: (Child 2)
*Fields are mandatory