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Holiday Programme
Customer enrolment details

Birkenhead Pool and Leisure Centre

Swimming Authorization:
I give permission for my child/ren to participate in swim activities at the Birkenhead Pool and Leisure Centre.

*Children aged 10 years and under will swim in the small pool unless they can confidently swim 15 metres unaided, as assessed by holiday programme or aquatics staff. We will no longer be providing life jackets to non-confident swimmers.

Holiday Programme terms and conditions:

  1. Auckland Council's terms and conditions apply, and become binding when you enrol in a Council Recreation programme. Council, in its sole discretion may refuse to accept any application for enrolment from any person.
  2. Unless otherwise advised by Council, you will need to pay all programme fees at the time of your enrolment. You acknowledge that if you do not pay programme fees when required, you will not be able to participate in your programme.
  3. You agree to follow all the instructions given by Council's representatives, remain in areas designated by Council's representatives, comply with any applicable Council policies and refrain from behaviour that could cause injury or harm to other participants in the programme or their Council property.
  4. You acknowledge that your personal possessions are your own responsibility when undertaking a programme.
  5. You undertake the programme at your own risk. You acknowledge that Council, nor anyone associated with Council will be liable for any injury or accident you incur while participating in a Council programme or for any damage or loss to your personal effects.
  6. In the event of any sickness or accident occurring while you are participating in the programme, you acknowledge that qualified medical attention may be obtained at your expense by Council and that your emergency contact will be notified.
  7. Council Fitness Centres are public places and Council may photograph the facilities for marketing purposes. You agree that if your image is captured it may be used in marketing material by Council or an agency or media outlet. Council will obtain written consent for any image that focuses on individual.
  8. There are no refunds after the commencement of a Council programme. If you cancel prior to commencement of your programme a refund will only be made if the programme is full and your space can be reallocated to someone on the waiting list. If a refund is given, you may choose to take a credit on your Council account or have the funds transferred by direct debit in your bank account. Council does not provide cash refunds.
  9. You must observe an appropriate standard of dress and wear clothing and footwear suitable for the activity in which you're engaged. Coloured bandanas or clothing denoting gang affiliations are not permitted. You will also bring any relevant equipment required for your Council programme, as advised by Council from time to time.
  10. You agree to behave appropriately and will not engage in disruptive, dangerous, or unseemly conduct while participating in a Council programme. Participants must leave the site of the Council programme if asked to do so by an authorized Council representative.
  11. Participants are required to maintain Council's high standard of cleanliness and the good order of its facilities. You will be responsible for all damage you cause, whether directly or indirectly, to equipment or facilities and you in dignify Council against any loss if suffers or incurs as a result of such damage.
  12. Council may change the programme structure, content or equipment at any time.
  13. You agree to provide any information requested by Council concerning the state of your health or physical wellbeing. You must provide a medical certificate if requested. You warrant that you have the level of fitness required to undertake your chosen programme and its activities.
  14. No unauthorized commercial activity, advertising or recruiting for business may take place on any Council premises or site where a Council programme takes place.
  15. Council may need to obtain personal information from you for the purposes of enrolment. Council may need to disclose your personal information to staff and contractors. Council will take all reasonable precautions to protect your personal information from misuse, loss, unauthorized access, modification or disclosure. Under the Privacy Act 1993 you have the right of access to, and correction of, personal information held by Council.
  16. If you have enrolled a child in a Council programme these terms and conditions will apply to your child's participation in the Council programme. You will ensure that your child complies with these terms and conditions as applicable to him or her. Council is not responsible for the safety of children or participants outside programme hours. You acknowledge that if you are late in collecting your child from the Council programme you will incur an additional charge.
  17. Your participation in the programmes is subject to these terms and conditions, any relevant Council policies, industry body standards, and New law
  18. If you have enrolled a child a Council programme you are required to provide Council with clear instructions regarding persons authorized to collect your child. Where there are custody issues a copy of the court order must be supplied. A policy document detailing Council procedure regarding access to children is available at each centre.
  19. I give my permission for my child to be transported to and from school, to and from venues during the holiday programme, by Auckland Council staff in Auckland Council vehicles, vans or buses.

  By submitting this form, you agree all information provided is true and correct to the best of your knowledge. You agree that once signing this form you are bound within the terms and conditions listed above.

Today's Date: February 23, 2020

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

Medical conditions or allergies?

Behavioural/special/cultural needs:
Age*
Promotional Photo Disclaimer: I give permission for my child/ren's photo(s) to be taken and if required used for promotional purposes.*
No
Yes
Main or Small Pool?*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Medical conditions or allergies?

Behavioural/special/cultural needs:
Age*
Promotional Photo Disclaimer: I give permission for my child/ren's photo(s) to be taken and if required used for promotional purposes.*
No
Yes
Main or Small Pool?*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Medical conditions or allergies?

Behavioural/special/cultural needs:
Age*
Promotional Photo Disclaimer: I give permission for my child/ren's photo(s) to be taken and if required used for promotional purposes.*
No
Yes
Main or Small Pool?*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Medical conditions or allergies?

Behavioural/special/cultural needs:
Age*
Promotional Photo Disclaimer: I give permission for my child/ren's photo(s) to be taken and if required used for promotional purposes.*
No
Yes
Main or Small Pool?*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Medical conditions or allergies?

Behavioural/special/cultural needs:
Age*
Promotional Photo Disclaimer: I give permission for my child/ren's photo(s) to be taken and if required used for promotional purposes.*
No
Yes
Main or Small Pool?*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Medical conditions or allergies?

Behavioural/special/cultural needs:
Age*
Promotional Photo Disclaimer: I give permission for my child/ren's photo(s) to be taken and if required used for promotional purposes.*
No
Yes
Main or Small Pool?*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Medical conditions or allergies?

Behavioural/special/cultural needs:
Age*
Promotional Photo Disclaimer: I give permission for my child/ren's photo(s) to be taken and if required used for promotional purposes.*
No
Yes
Main or Small Pool?*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Medical conditions or allergies?

Behavioural/special/cultural needs:
Age*
Promotional Photo Disclaimer: I give permission for my child/ren's photo(s) to be taken and if required used for promotional purposes.*
No
Yes
Main or Small Pool?*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Medical conditions or allergies?

Behavioural/special/cultural needs:
Age*
Promotional Photo Disclaimer: I give permission for my child/ren's photo(s) to be taken and if required used for promotional purposes.*
No
Yes
Main or Small Pool?*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Medical conditions or allergies?

Behavioural/special/cultural needs:
Age*
Promotional Photo Disclaimer: I give permission for my child/ren's photo(s) to be taken and if required used for promotional purposes.*
No
Yes
Main or Small Pool?*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Address

Address Line 1: (Street address, P.O. box, company name, c/o) *

Address Line 2: (Apartment, suite, unit, building, floor, etc.)

Country: *

City: *
Guardian details

Parent/guardian 1 *

Phone *

Relationship *
Emergency Contacts

(must be available for contact between 8am-6pm)


Emergency Contact Name *

Phone *

Relationship *
Person(s) authorised to collect my child(ren)
Both parents/guardians?*
No
Yes

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

Person(s) denied access to my child(ren) (please provide a copy of the court order):
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Medical conditions or allergies?

Behavioural/special/cultural needs:
Age*
Promotional Photo Disclaimer: I give permission for my child/ren's photo(s) to be taken and if required used for promotional purposes.*
No
Yes
Main or Small Pool?*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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