REGISTRATION FORM - CONDOBOLIN 2024

Please fill in the following form to enrol in our physical culture classes in Condobolin. Information for classes in 2024 will be emailed late January 2024. You will be required to sign an additional BJP form and pay your registration fee prior to your registration being complete. You can sign and pay at one of our scheduled open days or by arrangement prior to class.

Name of person completing this form

First Name

Last Name

What is your relationship to the member?

Member Details

First Name

Last Name

Preferred Name

Date of birth

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone Number

(###)

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Mobile Phone Number

(###)

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Email

Parent/ Carer/ Emergency Contact 1 Name

First Name

Last Name

Emergency Number of Parent/ Carer/ Emergency Contact 1

(###)

###

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Parent/ Carer/ Emergency Contact 2 Name

First Name

Last Name

Parent/ Carer/ Emergency Contact 2 Details

(###)

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I give consent for the images of me/my child to be used in publicity for the club.

Yes

No

I give consent for a trained first aid officer to administer first aid to me/my child if required.

Yes

No

I give consent for an Ambulance to be called if deemed necessary for me/my child.

Yes

No

Please provide details of allergies/medication/injured or any other relevant medical information that me be of use while your child is attending class.