Inc No: A0018327L. ABN: 71 872 745 914. PO Box 116, Altona VIC 3018. 139 Esplanade, Altona, VIC, 3018. W: www.altonalsc.
ALTONA LIFE SAVING CLUB INC Inc No: A0018327L ABN: 71 872 745 914 PO Box 116, Altona VIC 3018 139 Esplanade, Altona, VIC, 3018 W: www.altonalsc.com.au
Swim Proficiency Declaration The Nippers program promotes junior life saving skills, physical activity and safety in and around water environments but it is NOT a learn to swim program. Children need to demonstrate basic swimming skills in order to be eligible to participate. The level of this proficiency varies depending upon their age and the requirements are listed on this form. The best person to determine your child’s proficiency is their regular swimming teacher or coach. Please complete your child’s name and age group based on their date of birth from the table below and ask their swim teacher or swim coach to complete the declaration at the bottom of this page including the time taken to complete the required swim and any other comments. We would like to thank you for your assistance in ensuring the safety of our participants. AGE GROUP
DATE OF BIRTH
SWIM REQUIREMENTS
PLEASE TICK
SURVIVAL FLOAT
Under 6
1/10/10 - 30/09/11
Nil - shallow water activities only
Nil
Under 7
1/10/09 - 30/09/10
Nil - shallow water activities only
Nil
Under 8
1/10/08 - 30/09/09
25m swim - any stroke
1 minute survival float
Under 9
1/10/07 - 30/09/08
25m swim - any stroke
1 minute survival float
Under 10
1/10/06 - 30/09/07
25m swim - freestyle
90 second survival float
Under 11
1/10/05 - 30/09/06
50m swim - freestyle
2 minute survival float
Under 12
1/10/04 - 30/09/05
100m swim - freestyle
2 minute survival float
Under 13
1/10/03 - 30/09/04
150m swim - freestyle
3 minute survival float
Under 14
1/10/02 - 30/09/03
200m swim - freestyle in less than 5 minutes
3 minute survival float
SWIM TEACHER / COACH DECLARATION I confirm that _____________________________ can complete the requirements appropriate for his/her age & date of birth above. Name: Signature: Time:
Organisation: Phone No:
Date:
Comments:
For all enquiries or to submit completed forms please email to
[email protected] 
