DPA Lifejacket Hub Request Form

Your details

Please complete the following short survey to indicate which DPA Lifejacket Hub you would like to loan lifejackets from.

1. Contact name? *This question is required.

Space Cell	First Name	Surname
Name	Name: First Name	Name: Surname

2. Your Mobile number? *This question is required.

3. Your email address? *This question is required.

4. Size of lifejackets required . (Please Note, All Auckland orders over 15 jackets need to be picked up from Drowning Prevention Office or Sport Waitakere) *This question is required.

Space Cell	Child XSmall (10-15kg)	Child Small (12-15kg)	Child Medium (22-40kg)	Adult Small (40+ kg)	Adult Medium (40+ kg)	Adult Large (40+ kg)	Adult XLarge (40+ kg)	Adult XXL (40+ kg)
Quantity	Quantity: Child XSmall (10-15kg)	Quantity: Child Small (12-15kg)	Quantity: Child Medium (22-40kg)	Quantity: Adult Small (40+ kg)	Quantity: Adult Medium (40+ kg)	Quantity: Adult Large (40+ kg)	Quantity: Adult XLarge (40+ kg)	Quantity: Adult XXL (40+ kg)

Which lifejacket hub would you like to loan from? (Note for Auckland Schools, Lifejackets to be collected from DPA Office or Sport Waitakere for West Auckland Schools) *This question is required.

6. What date would you like to pick up the lifejackets? *This question is required. This question requires a valid date format of DD/MM/YYYY.

calendar

7. What date will you return lifejackets ? *This question is required. This question requires a valid date format of DD/MM/YYYY.

calendar

Are you loaning for: *This question is required.

If you are loaning for a School or Organisation, please provide these details below eg Mt Albert Primary School or Belgravia Pool If its for personal use please put down 'None' *This question is required.

8. We may contact you via email with information about resources, programmes or activities which we believe may be of interest to you. Please select whether you would like to be contacted or prefer not to. *This question is required.