Melville Enrolment Form

Please note fields marked with (*) are required.

Enrolment Information

Surname(*)
Please enter your Surname

Parent Name(*)
Please type your full name.

Address(*)
Please include your address

Suburb(*)
Invalid Input

Post Code(*)
Please include your post code

Mobile Phone(*)
Please include your mobile phone number

Email(*)
Please include your email address

Emergency Contact(*)
Please enter the name of an Emergency Contact

Phone No(*)
Please enter the phone number for the Emergency Contact

Notes for Enrolment
Invalid Input

 
Swimmer 1(*)
Please include Swimmer 1 Name

Level
Invalid Input

DOB
Invalid Date of Birth for Swimmer 1

Medical Conditions
Invalid Input

Lesson Request

Please provide TWO options for each swimmer

Swimmer 1 Option 1
Invalid Input

Time
Invalid Input

Swimmer 1 Option 2
Invalid Input

Time
Invalid Input

 
Swimmer 2

Level
Invalid Input

DOB
Invalid Date of Birth for Swimmer 2

Medical Conditions
Invalid Input

Lesson Request

Please provide TWO options for each swimmer

Swimmer 2 Option 1
Invalid Input

Time
Invalid Input

Swimmer 2 Option 2
Invalid Input

Time
Invalid Input

 
Swimmer 3

Level
Invalid Input

DOB
Invalid Date of Birth for Swimmer 3

Medical Conditions
Invalid Input

Lesson Request

Please provide TWO options for each swimmer

Swimmer 3 Option 1
Invalid Input

Time
Invalid Input

Swimmer 3 Option 2
Invalid Input

Time
Invalid Input

 

Credit Card

By completing the credit card information below, I request and authorise Kirby Swim to arrange, through its own financial institution, a debit to your nominated account any amount Kirby Swim, has deemed payable by you.

This debit or charge will be made through the Bulk Electronic Clearing System (BECS) from your account held at the financial institution you have nominated below and will be subject to the Terms and Conditions of the Direct Debit Request Service Agreement.

Please note, we only accept Visa and MasterCard for credit card payments. Your payment will not be processed until your booking is confirmed by Kirby Swim.

Credit Card #
Visa or MC ONLY
Please enter a valid Credit Card number

Card Holder Name
Invalid Input

Expiry Date
Invalid Input

Amount
Invalid Input


Bank Account - Cheque or Savings

By completing the bank account information below, I request and authorise Kirby Swim to arrange, through its own financial institution, a debit to your nominated account any amount Kirby Swim, has deemed payable by you.

This debit or charge will be made through the Bulk Electronic Clearing System (BECS) from your account held at the financial institution you have nominated below and will be subject to the Terms and Conditions of the Direct Debit Request Service Agreement.

Please note, your payment will not be processed until your booking is confirmed by Kirby Swim

FINANCIAL INSTITUTION INFORMATION
Financial Institution Name
Invalid Input

Suburb Account Opened
Invalid Input


DIRECT DEBIT INFORMATION
Account Name
Invalid Input

Amount Per Direct Debit ($)
Invalid Input

BSB Number
Invalid Input

Account Number
Invalid Input

Account Holder Address
Invalid Input

Account Holder Email
Invalid Input

Terms & Conditions(*)
Invalid Input

I agree to the Kirby Swim Terms & Conditions