Required fields are marked with an asterisk (*).
Given name *
Family name *
Date of birth *
This program is for children under 5 years of age.
Street address *
Address line 2
State / province / region *
-- 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
Phone number *
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 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.
Please provide any additional information you think we should know.
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 NT Branch or their agents in order to
administer the Program. You have the right to access
the information you provide and may do so by contacting
the Water Safety Awareness at firstname.lastname@example.org.
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
Last updated: 12 August 2019
Describe your experience
More feedback options
To provide comments or suggestions about the NT.GOV.AU website, complete our feedback form.
For all other feedback or enquiries, you must contact the relevant government agency.