EzySwim | Members - Notify An Absence With A Valid Medical Certificate



Make-up classes are granted only in the event of a genuine medical illness (with a valid medical certificate). Make up lessons are valid until the end of the month (year round venues) or term (seasonal venues) in which the session was missed and are subject to availability. Please attach a scanned copy of your medical certificate to this form or fax your medical certificate to 99763711 or mail it to Reply Paid 500 Manly NSW 1655 (no stamp required). Please note your request cannot be processed without your valid medical certificate. Once your valid medical certificate has been received you will be contacted within 2 business days to arrange your make-up lesson.



	Venue*:


	Surname:*


	Member First Name:

	Name #1*:

	Name #2:

	Name #3:


	Member Number: (if known)

	Member #1 :

	Member #2:

	Member #3:


	E-Mail*:


	Address:


	Contact Numbers:

	Home Phone:

	Work Phone:

	Mobile Phone:


	Day/s & Time/s of Class/es:

	Day #1*:

	Class Time #1*:



	Day #2:

	Class Time #2:



	Day #3:

	Class Time #3:

Date of First Absence:

Date of Final Absence:


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	Security code: