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*12345678910111213141516171819202122232425262728293031 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 19801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020

Age:

Years* Select One01234567891011121314

Months* Select One01234567891011

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 OneYesNo

Does your child put their face in the water / bath / shower? Select OneYesNo

Can your child swim unassisted without a floatie / puddle jumper / back float or something similar? Select OneYesNo

Primary School Age 5+

Does your child attend primary school? Select OneYesNo

Can your child swim unassisted, without a floatie / puddle jumper / back float or something similar? Select OneYesNo

What distances does your child regularly swim?

If your child is over 7 can they swim breaststroke and butterfly? Select OneYesNo

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)12345678910111213141516171819202122232425262728293031 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 19801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020

Age:

Years (Child 2) Select One01234567891011121314

Months (Child 2) Select One01234567891011

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 OneYesNo

Does your child put their face in the water / bath / shower? (Child 2) Select OneYesNo

Can your child swim unassisted without a floatie / puddle jumper / back float or something similar? (Child 2) Select OneYesNo

Primary School Age 5+

Does your child attend primary school? (Child 2) Select OneYesNo

Can your child swim unassisted, without a floatie / puddle jumper / back float or something similar? (Child 2) Select OneYesNo

What distances does your child regularly swim? (Child 2)

If your child is over 7 can they swim breaststroke and butterfly? (Child 2) Select OneYesNo

After completing the above is there anything more you feel we should know?

General Comments: (Child 2)

*Fields are mandatory