Swimming Recreation Facility Permit

* Mandatory Field

Application Details
Applicant Details
Permit Number

To be completed by the Southern Mallee District Council

Council Name

Please complete this form and return to the Council [ The Authority ]

Contact Name*
Organisation/Business Group Name*

The Permit Holder


Please include your Home and Mobile Telephone Numbers

Email Address*
Event Name and Dates
Event Name*
Date of the Event*
Event Hours*
Location of the Event*

Please select the location

Special Requirements

Please include any special requests

Name of the Life Guard*

Please include the name or names of the Lifeguard as outlined in the Terms and Conditions

Event Description
Activity Description*

Please Describe the Activity

Agree with the Terms and Conditions
Swimming Recreation Facility Terms and Conditions*

By ticking this box you are deemed to have read and agree with the Stallholder Terms and Conditions

Click Here to view the Terms and Conditions

Please attached current copy of your Insurance and any required Licences

Confirmation of Licenses, Insurances and Required Documents*

Please check this box if you have supplied the required documents outlined in the Terms and Conditions

If you see this, leave this form field blank.

Send a copy of the submitted form to this email address.