Do you have a concession? Yes No
Customer last name:
Customer given names:
Title: Mr.
Date of birth:
Mrs. Ms. Miss. Other, please specify
Customer last name:
Customer given names:
Title: Mr.
Date of birth:
Mrs. Ms. Miss. Other, please specify
Postal Address:
Town:
Postcode:
Business hours contact number:
After hours contact number:
Email address:
Customer last name:
Customer given names:
Gender: Male Female
Date of birth:
P A G E 1

LATROBE LEISURE
Age:
Preferred day:
Preferred time:
Medical conditions and medications:
Concession card expiry:
Customer last name:
Customer given names:
Gender: Male Female
Date of birth:
Age:
Preferred day:
Preferred time:
Medical conditions and medications:
Concession card expiry:
Customer last name:
Customer given names:
Gender: Male Female
Date of birth:
Age:
Preferred day:
Preferred time:
Medical conditions and medications:
Concession card expiry:
Customer last name:
Customer given names:
Gender: Male Female
Date of birth:
LEARN TO SWIM MEMBERSHIP
P A G E 2

LATROBE LEISURE
Age:
Preferred day:
Preferred time:
Medical conditions and medications:
Concession card expiry:

Admin fee paid

Progress book received

Family Number:
LEARN TO SWIM MEMBERSHIP
Please select all the days available to attend
Monday Tuesday Wednesday Thursday
Earliest lesson start time:
Earliest lesson finish time:
Please select all the days available to attend
Monday Tuesday Wednesday Thursday
Earliest lesson start time:
Earliest lesson finish time:
Please select all the days available to attend
Monday Tuesday Wednesday Thursday
Earliest lesson start time:
Earliest lesson finish time:
Please select all the days available to attend
Monday Tuesday Wednesday Thursday
Earliest lesson start time:
Earliest lesson finish time:
Friday
Friday
Friday
Friday
Saturday Sunday
Saturday Sunday
Saturday Sunday
Saturday Sunday
P A G E 3

LATROBE LEISURE
Last name:
Given names:
Business hours contact number:
Relationship to student:
Last name:
Given names:
Business hours contact number:
Relationship to student:
LEARN TO SWIM ENROLMENT
The personal information requested on this form is being collected by Council for the purpose of enrolling you and/or your child/ren as an aquatic education participant in the Latrobe City Leisure Facilities swim program. The personal information you provide will be used solely by Council for that primary purpose or directly related purposes.
I hereby grant permission for Council, the right to use my photo and my child/ren’s photo (physical likeness) as part of my membership information. This is required for security purposes to ensure that only the nominated member/s can gain access to the facilities. The image will not be used in promotions of programs, projects or events. I accept that no fee or remuneration will be provided for my or my child/ren’s appearance on the membership database.
The information relating to any health issues is required so the staff will be able to give you and/ or your child/ren the best support available. This information will be used solely by Council for that primary purpose or directly related purposes.
If you choose not to provide this information, then we will be unable to process your application. The applicant understands that the personal and health information provided is for the reasons outlined above and that he or she may apply to Council for access to and/or amendment of the information. Requests for access and/or correction should be made to the Privacy Officer of
Latrobe City Council on 1300 367 700.
P A G E 3

LATROBE LEISURE LEARN TO SWIM MEMBERSHIP
As responsible person of (list all children)
I, give consent for their participation in the Latrobe Leisure Learn to Swim Program.
 I am aware that this is an ongoing membership and it is my responsibility to cancel this membership in writing for the membership to cease. I will be charged for any lessons up to the date this cancellation is received.
 I agree to delegate authority to the staff members and instructors involved.
 Where it is impracticable to communicate with me, I authorise the person in charge, in the event of any illness or accident, to obtain on my behalf any such medical assistance as my child/ren may require and I agree to bear any cost thereby incurred.
 I understand, as responsible person, that it is my responsibility to present my child/ren to their appropriate instructor at the commencement of each lesson and also be present on pool deck to collect my child/ren at the end of each lesson.
 I further acknowledge that I/ We agree that neither the Latrobe City Council, nor its officers and servants, will be liable for any damage, loss or injury how so ever caused or of what so ever nature that may be incurred by my child/ren in attending the venue or activities in the said program.
 I have read and accept the above Responsible Person Declaration and the conditions of the Latrobe City Learn to Swim
Client Service Agreement.
Signed:
Date:
Credit card Bank account
To Latrobe Leisure Facilities,
I/we request that you draw by way of the Direct Debit system from my/our account as per the following instructions:
 I have received a copy of and agree to the terms and conditions of the Learn to Swim Client Service Agreement.
 I agree to pay the pro rata fees on first attendance as per the Learn to Swim Client Service Agreement.
 I acknowledge that my Learn to Swim payments are ongoing until a cancellation form is received 10 days prior to cancellation date.
 I understand my fees will be paid out of my family credit balance on a monthly basis on the 14 th day of each month or the next business day. Where there is insufficient family credit, the balance will be charged to my nominated account.
 I acknowledge that any rejections will incur a $9 rejection fee and result in the immediate suspension of all my learn to swim membership for a period of 7 days. This suspension time will be deducted from the allowed suspension time for your membership. Failure to finalise outstanding fees within 7 days will result in the cancellation of my learn to swim membership and the outstanding balance will be invoiced to me including a $15 fee.
P A G E 5

LATROBE LEISURE LEARN TO SWIM MEMBERSHIP
 I understand that lessons will operate on a weekly basis at my nominated day and time as a perpetual program.
Suspensions or missed lessons must be notified as per the Learn to Swim Client Service Agreement.
Please complete only if deductions are to be taken from nominated bank account.
Bank and branch name:
BSB Number (six digits required):
Account number:
Account name:
Postal address:
Town:
Postcode:
Contact number:
Complete if deductions are to be taken from a credit card
Financial Institution:
Card type: Visa Mastercard
Card number:
Name (as it appears on card):
Expiry:
Postal address:
Town:
Postcode:
Contact number:
Signature of account/card holder (joint accounts require both signatures):
Date:
 Concession card copied and attached
 Credit card or bank details have been completed (this is required even if the customer is paying cash)
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LATROBE LEISURE LEARN TO SWIM MEMBERSHIP
 Customer has signed the declaration and card holder has signed the debit request
 Booking fee has been charged
 Progress book has been issued
 Latrobe City Learn to Swim Client Service Agreement (at the end of this document) has been given to the customer
To be signed and checklist above completed by staff member that receives the form
Received date: Staff name: Staff signature:
To be completed by staff member that makes and confirms the booking (supervisor or authorised staff).
Booking confirmed date: Staff name: Staff signature:
 Direct debit details entered
 Concession expiry date entered
 Entered on Links
 Written in folder
 Card ordered
Date entered: Supervisor Name: Supervisor Signature
P A G E 7

LATROBE LEISURE LEARN TO SWIM MEMBERSHIP
All fees must be paid in full by the 14 th of each month. Failure to do so will result in the immediate suspension, of all learn to swim memberships, for a period of 7 days. This suspension time will be deducted from the allowed suspension time for your membership. Failure to finalise outstanding fees within 7 days will result in the cancellation of all learn to swim memberships and an invoice being sent to you with the balance. This will incur a $15.00 administrative fee.
It is your responsibility to present a current concession card prior to the expiry of any listed concession cards in order to continue to receive the concession discount. Failure to do so will result in your learn to swim fees being charged at the full rate until such time that you update these details.
Your concession discount will not be backdated.
If your child misses a lesson due to medical reasons, a credit will be added to your account after the passing of all dates noted on the medical certificate or within 30 days of the presentation of a valid medical certificate from a General Practitioner, whichever occurs later. Medical Certificates are accepted at any stage throughout the year.
Progress books will be updated when your child completes a level. You will be notified and requested to bring your progress book in at that time. Progress books need to be handed in at front reception and will be returned to you within 4 weeks.
Instructors do not accept progress books at any stage.
If you choose to cancel lessons at any stage, you will be required to complete a cancellation form and a $15.00 cancellation fee will apply. Memberships that have been held for 10 months or more or the completion of level 10 will be exempt from the cancellation fee. You will be charged for all lessons up to the date the cancellation form is received.
If you choose to suspend your membership, a suspension form needs to be submitted prior to the suspension date or at the first lesson returned after the suspension date has occurred. Students are entitled to one week suspension per three months membership up to a maximum of four weeks suspension per year. You will not be charged for suspended lessons.
All students will receive a complimentary season pass allowing access to the indoor pools at Latrobe Leisure Morwell, Moe
Newborough and Churchill for the student or where the student is under four years, for the student and their responsible guardian (Children under four must have a guardian over 16 years accompany them in the water). Season passes are valid from the 1 February to 24 December. The Learn to Swim season pass is limited to recreational use and not valid for programs such as school swimming, swimming club, group bookings etc.
All queries must be directed to the Learn to Swim Supervisor. You must present your Learn to Swim card and have a valid photo on file when accessing any Centre. Priority will be given to those parents who present cards ahead of those who don’t. A $2.00 replacement fee applies for lost Learn to Swim cards.
Your child must be collected at the conclusion of their lesson. All children under the age of 10 years old must be supervised at all times by a guardian over the age of 16. Children under 4 years old must be actively supervised in the water by their guardian outside of lesson times.
This membership is ongoing until advised by you in writing using a “Learn to Swim Request for Changes” form or on completion of Level 10.
P A G E 8

LATROBE LEISURE LEARN TO SWIM ENROLMENT
On the 14 th of each month, or next business day, fees will be charged for the number of lessons booked for the following month.
Fees will be deducted from the family credit where funds are available. Any fees not covered by the funds in the family credit will have a Direct Debit Request made to your nominated account.
A pro rata is calculated for all lessons from the date you join until the 13 th of the month. The pro rata amount will be payable on you first lesson.
There is a non-refundable booking fee applicable to this membership. This fee covers the cost of your assessment (if required), your child’s pool admission for the purpose of the assessment, a progress book and all administration required to process your booking request.
A pro rata Learn to Swim booking payment applies to be financial up to the 14 th of the month
 Payments will change monthly according to the number of lessons in the following month. Please refer to the fees and charges brochure for a full list of lesson prices.
 Monthly payments will take into account for public holidays, medical certificates and suspensions, where your payment will be reduced
 If any changes to your membership of any nature are required a “Learn to Swim request for changes” form will need to be completed.
 These amounts will be deducted from the nominated account until Latrobe Leisure receives a completed cancellation form or at the completion of Level 10.
 If a transaction from the nominated account is returned to Latrobe Leisure unpaid, a $9.00 bank fee is charged and this fee will be passed onto the Direct Debit swim booking.
 If a transaction is rejected the customer’s booking will be suspended for 7 days. Failure to make payment of the rejected amount within 7 days will result in the responsible fee payer being invoiced via Latrobe City Council. This will include a
$15.00 invoicing fee.
Termination of the Learn to swim membership will only be done upon completion of the “Learn to Swim Cancellation Request” form. This form must be presented to a Latrobe Leisure Centre for processing to occur.
 Latrobe Leisure must receive notice to terminate at least 10 business days prior to the requested cancellation date.
 Any fees outstanding at the time of cancellation must be paid at the time of the direct debit cease request.
 Unpaid fees will be passed on to Latrobe City for debt collection and include a $15.00 administration fee.
 A $15.00 cancellation fee will apply to memberships that have been held for less than 10 months. The completion of level 10 will be exempt from the cancellation fee.
Learn to Swim members are entitled to a season swim pass for the student currently enrolled. This pass is valid from 1 February until 24 December each year at all Latrobe Leisure indoor pool facilities. The Learn to Swim season pass will be expired if the
Direct Debit contract is terminated by the customer or Latrobe Leisure or if your payment is in arrears. The Learn to Swim
P A G E 9

LATROBE LEISURE LEARN TO SWIM MEMBERSHIP season pass is limited to recreational use and not valid for programs such as school swimming, swimming club, group bookings etc.
We will only arrange for funds to be debited from your account:
 As authorised in the Latrobe City Direct Debit Request (LCDDR); and/Or
 According to any notice sent to you by Latrobe City Council specifying the amount payable and the date the payment is due.
Where the due date falls on a non-business day, we will draw the amount on the next business day.
We will not change the frequency of drawing arrangements without your prior approval.
The amount drawn each month will vary due to the number of lessons that month.
We reserve the right to cancel the LCDDR drawing arrangements if any drawings are returned unpaid by your nominated
Financial Institution and to cancel all associated memberships.
A fee to recover costs will be charged if:
 Drawings are returned unpaid by your nominated Financial Institution for whatever reason.
 The wrong or incomplete BSB and Account Number are given and as a result the drawings are returned unpaid to us.
Latrobe Leisure drawing dates will be as set out in the Latrobe City Learn to Swim Client Service Agreement.
We may vary this agreement at any time by giving you at least 10 business days notice.
We will keep all information, in your direct debit request, pertaining to you & your nominated account at the Financial Institution, private and confidential.
We will make reasonable efforts to keep any such information that we have about you secure and to ensure that any of our employees or agents who have access to information about you do not make any unauthorised use, modification, reproduction or disclosure of that information.
We will only disclose information that we have about you:
 To the extent specifically permitted by the law; or
 For the purpose of this agreement (including disclosing information in connection with any query, dispute or claim); or
 To verify details with your Financial Institution if required (e.g. BSB and bank account number)
You may terminate the Latrobe City Direct Debit Request drawing arrangements, at any time, by completing a “Learn to Swim
Cancellation” form. We should receive such notice at least 10 business days prior to the due date and before you give notice to your Financial Institution. This will also terminate your membership.
Where you consider that a drawing has been initiated incorrectly [outside the LCDDR arrangements] you should take the matter up directly with us and as soon as possible so that we can resolve your concern quickly.
P A G E 10

LATROBE LEISURE LEARN TO SWIM MEMBERSHIP
If the drawing is not as per the instructions of the LCDDR action will be taken, within 28 business days to either adjust or refund the incorrect drawing to the account from which it was drawn.
If the drawing is as per your instructions we will provide you with reasons or copies of any documents which we believe justify the view we have taken.
Any queries you may have about an error made in debiting your account should be directed to us in the first instance so that we can attempt to resolve the matter between us and you. If we cannot resolve the matter you can still refer it to your financial institution who will obtain details from you of the disputed transaction and may lodge a claim on your behalf.
By signing the Latrobe City Direct Debit Request, you authorise us to arrange for funds to be debited from your account according to the agreement we have with you.
It is your responsibility to ensure that sufficient funds are available in family credit or the nominated account to meet a drawing on its due date.
It is your responsibility to ensure that the authorisation given, in writing, to draw on the nominated account, is identical to the account signing instruction held by the Financial Institution where the account is based.
It is your responsibility to advise us, in writing, no less than 10 business days, if the account nominated by you to receive the
Latrobe City Direct Debit Request drawings is transferred or closed or if you wish to terminate the Latrobe City Direct Debit
Request.
It is your responsibility to arrange with us a suitable alternate payment method if the LCDDR drawing arrangements are cancelled either by yourselves or your nominated Financial Institution
P A G E 11