Private Swimming Instructor Application

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This field is for validation purposes and should be left unchanged.

Unique ID

Private swim instructors wishing to operate at Leeton Regional Aquatic Centre and Whitton Pool are required to complete this form in full and provide the requested documentation.

Privacy: Information collected with this form will be used in compliance with Council's Privacy policy.

Instructor Details

Name(Required)

First Last

Date of birth(Required)

Phone(Required)

Address(Required)

Email(Required)

Swim Teaching Accrediation(Required)

Upload a copy of your Swim Teaching Accrediation.

Max. file size: 128 MB.

Accreditation Expiry Date(Required)

Public Liability Insurance(Required)

Upload a copy of your public liability insurance.

Max. file size: 128 MB.

Permission to Display Details(Required)

I give permission for my name and contact details to be displayed in the pool kiosk for public enquiries:

Yes

Contact me next season to renew my application

Yes

Signature(Required)

Application Date

Private Swim Instructor

Price:

Credit Card(Required)

Card Details

Cardholder Name

Alternate Payment Required

Yes

Alternate Payment Method(Required)

Alternate Payment Receipt(Required)

Additional Informaton

Provide details of what's required, this will be included in the email.

Declined Reason(Required)

Provide details of why this application has been declined. This will be added to the notification to the applicant.