Please enter Parent or Responsible person details
First Name :
*
Last Name :
*
Email Address :
*
Login Password :
*
Gender :
Male
Female
Other
Unknown
*
Date of birth :
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
January
February
March
April
May
June
July
August
September
October
November
December
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
*
Street Address :
*
Suburb :
*
State :
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
*
Post Code :
*
Primary Contact :
Mobile Phone
Home Phone
Work Phone
*
Include Area Code
## #### ####
Secondary Contact :
Mobile Phone
Home Phone
Work Phone
Enter Phone as
#### ### ###
Additional Contact :
Mobile Phone
Home Phone
Work Phone
Include Area Code
## #### ####
How did you hear about us? :
14 Day Membership
3rd Party Billing
Academy Memberships
Accelerate
Access Housing Corporate
Alcoa Corporate
Brochure
Casual User
Centrelink Corporate
Clubs/Organisations
Coast FM/The Wave Corporate
CoM Employee
COM Employee Subsidised
Coolibah Aged Care Corporate
CSBP Corporate
DCP
Defence Force Army Navy Airforce Corporate
Downgrade Membership-Wellness Centres
DVA
Ed Dept or School Group
Email
Facebook
FIFO
Fire and Emergency Services Corporate
Fitness Passport
Free Pass
Gift
Gift Certificate
Gift Certificate - winner
Housing Choices WA
In centre
Internet/Googled
LJ Hooker Corporate
Mandurah Basketball Financial Members Corporate
Mandurah Magic
Midway Corporate
Newspaper
Nurses/Doctors Corporate
Opal Aged Care Corporate
Peel Acadamy
Peel Development Commission Corporate
Peel Health Corporate
Peel Lightning Netball
Physio
Previous Customer
Public Trustee
Radio
Referral
Rehab client
Rio Tinto Corporate
Royal Life Saving Society WA
School Holiday Membership
SMS
Squash Club Member
St Johns Corporate
Student - Consent
Support Worker
Swim Club
Teachers / School Staff Corporate
Test
Vacation Swim leson participant
W.A Police Corporate
WA Dept of Communities Corporate
Walk In
Website
*
Emergency Contacts
Primary Contact Name :
*
Relationship :
*
Contact Number:
Mobile Phone
Home Phone
Work Phone
*
Include Area Code
## #### ####
Mobile Phone
Home Phone
Work Phone
Enter Phone as
#### ### ###
Secondary Contact Name :
Relationship :
Contact Number :
Mobile Phone
Home Phone
Work Phone
Include Area Code ## #### ####
Mobile Phone
Home Phone
Work Phone
Enter Phone as ## #### ####