Figtree Anglican Church -- Leaders Registration

Leaders Registration

Please note, registration and a $50 deposit is due by Friday 16th December, 2011. Full payment for leaders is $170 price due by Friday January 6th, 2012. After this date, it will rise to $180.

Ignite Camp Registration (Leaders)

Surname:
First Name:
Role on Camp:
Postal Address:
Mobile Phone Number:
Email Address:
Emergency Contact:
Emergency Contact Tel (Home):
Emergency Contact Tel (Mob):
Medicare No:
Card Ref. No:
Expiry Date:
Insurance Company:
Membership Number:
Date of last Tetanus Booster:
Please list dietary needs, allergies, behavioural difficulties, medication or other conditions:
I will NOT be travelling to and from Ignite on the bus:	(We strongly encourage all leaders to travel on the bus)
I will be paying by:	Direct Debit Cash/Cheque

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Leaders Registration

Ignite Camp Registration (Leaders)