Water safety awareness program registration form

Required fields are marked with an asterisk (*).

Child's name

Given name *

Family name *

Date of birth * This program is for children under 5 years of age.

Parent or guardian details

Given name *

Family name *

Address

Street address *

Address line 2

City *

State / province / region *

Country * -- Please Select --New ZealandUnited StatesAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaNagorno-KarabakhBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChilePeople's Republic of ChinaColombiaComorosCongo - KinshasaCongo - BrazzavilleCosta RicaCote d'IvoireCroatiaCubaNorthern CyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaSouth OssetiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaPridnestrovie (Transnistria)MonacoMongoliaMontenegroMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomalilandSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweTaiwanChristmas IslandCocos (Keeling) IslandsNorfolk IslandNew CaledoniaClipperton IslandMayotteSaint MartinSaint Pierre and MiquelonWallis and FutunaBouvet IslandCook IslandsNiueTokelauGuernseyIsle of ManJerseyAnguillaBermuda

Contact details

Phone number *

Email *

Select your required program

Program conditions

1. I understand vouchers are issued to the child listed on this form and may not be used for another child.

2. The child listed on this form is an NT resident.

3. I understand the vouchers are valid when my child turns 6 months and must be used before the expiry date and before the child turns 5 years of age.

4. I accept full responsibility for supervision of the child before, during and after each session.

5. I accept full responsibility for the child’s belongings before, during and after each session.

6. I accept that I must attend and interact with the child in all water sessions.

7. I accept full responsibility for expenses that may be incurred outside the voucher conditions.

8. I will abide by conditions set by session providers.

Permission details

Additional information Please provide any additional information you think we should know.

Privacy statement

The Northern Territory Government will use the information supplied on this form, or in discussions about this form, to facilitate the Water Safety Awareness Program.

The information will be supplied to the Royal Life Saving Society (RLSS) NT Branch or their agents in order to administer the program.

You have the right to access the information you provide. You can do this by contacting RLSS at wsap@rlssa.org.au.

Use of photographs: By signing the above, you agree to allow photographs taken of your child during Water Safety Awareness Program activities to be used in future promotional materials developed by the Northern Territory Government. This may include, but is not limited to the promotion of Water Safety Awareness program.