DPA Lifejacket Hub Request Form

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

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.

DPA Lifejacket Hub Request Form

Your details